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SURGICAL ASEPSIS 



PALMER 



SURGICAL ASEPSIS 



Especially Adapted to Operations in the 
Home of tlie Patient 



HENRY B PALMER, M.D. 

Consulting Surgeon to the Central Maine General Hospital 



WITH NINETY ILLUSTRATIONS 




' ..^^' '' ^ 



PHILADELPHIA 

F. A. DAVIS COMPANY, PUBLISHERS 

1903 




THE Library of 

CONGRESS, 
Two Copies Received 

MAY 12 1903 

Copyright Entry 

CUASS CC- XX©= No 
f ^ ^ t>' 

copy e. 



COPYRIGHT, 1903, 

BY 

F. A. DAVIS COMPANY. 
[Registered at Stationers' Hall, London, Eng.] 



Pliiladelphia, Pa., U. S. A. : 

The Medical Bulletin Printing-house, 

1914-16 Cherry Street. 



PREFACE. 



The aims of this book are to demonstrate that 
surgical work may be safely performed in the home 
of the patient, and to detail the methods which the 
writer has found best to secure ^such a result. 

If the home be a good one,' and if the same de- 
gree of surgical skill and nursing can be secured, 
the home treatment of surgical cases ofTers some 
very decided advantages over the hospital. The 
home environments, the greater degree of quiet 
which may be secured, and the knowledge of the pa- 
tient that he is among his friends and under the care 
of his family physician are great aids toward secur- 
ing that quietude of mind which will hasten the re- 
covery. 

After convalescence is established the patient is 
usually anxious to leave the hospital, and often re- 
turns to his home sooner than it is advisable that he 
should travel. Were he operated on at home he 
would neither be subjected to this risk nor would 
the convalescence be retarded by his anxiety to re- 
turn home. 

The methods described in this volume embody 
the principles conmionly accepted, modified in the 
manner found most convenient for house-to-house 

(ii>) ■ 



IV PREFACE. 

Operating. It has been written especially for those 
surgeons who often operate outside of the hospital, 
and for the general practitioner who may do some 
surgery or has the after-care of surgical cases. 

Only so much of bacteriology and theory have 
been included as has seemed necessary to the full 
understanding of the requirements for aseptic work, 
and to prove the ground taken on some unsettled 
points. 

The author has availed himself of the writers on 
aseptic technique, and would especially acknowledge 
the assistance received from the works of Scliimmel- 
busch, Kelly, and Robb. 

Farmington, Maine. 



CONTENTS. 



CHAPTER I. PAGE 
General Considerations of Aseptic Wound Treatment 1 

CHAPTER II. 
Pathogenic Bacteria 10 

CHAPTER III. 
Sources of Infection 20 

CHAPTER IV. 
Means of Sterilization 25 

CHAPTER V. 
Practical Application of the Principles of Sterilization 49 

CHAPTER VI. 
Accessories Necessary for Operation 65 

CHAPTER VII. 
Gauze, Sponges, Ligatures, and Sutures 77 

CHAPTER VIII. 
Drainage of Wounds 89 

CHAPTER IX. 
Dressing of Wounds 98 

CHAPTER X. 
Preparation for Operation by the Nurse 102 

CHAPTER XI. 
Organization for Operation 107 

CHAPTER XII. 
Peritoneal Toilet; Suturing and Dressing the Wound Ill 



VI CONTENTS. 

CHAPTER XIII. ^^^''^ 
After-treatment 119 

CHAPTER XIV. 
Vaginal Operations 127 

CHAPTER XV. 
Armamentarium of the Surgeon 136 

CHAPTER XVI. 
Infected Wounds 147 

CHAPTER XVII. 
Minor Aseptic Procedures 159 

CHAPTER XVIII. 

Constitutional Disturbances due to Wounds and their Infec- 
tions 172 

CHAPTER XIX. 
Aseptic Midwifery 197 

Index 229 



CHAPTER 1. 

GENERAL CONSIDERATIONS OF ASEPTIC 
WOUND TREATMENT. 



The results which follow the aseptic treatment 
of wounds have not only made it possible for the 
general practitioner to undertake surgical work 
wdiich formerly would have been impracticable for 
him to do, but they have forced upon him obliga- 
tions, in sudden emergencies, which he cannot escape. 

Moreover, in private surgical practice it is often 
the family physician who must direct the details of 
the preparation for the operation, assist in its per- 
formance, and carry out the suggestions of the sur- 
geon in the dressing of the wound and the after-care 
of the patient. He must therefore thoroughly un- 
derstand the principles and technique of aseptic sur- 
gical work, even though he does no operative work. 
I By an aseptic in contradistinction to an antiseptic 
technique we mean one in which every article that 
comes in contact with the wound has been previously 
freed from active organisms, and one in which no 
chemical antiseptics are employed in contact with 
the wound. On the other hand, the antiseptic tech- 
nique presupposes a certain amount of contamina- 
tion of the wound, and attempts to destroy, by chem- 
ical substances, the bacteria which have gained access 
to it. \ 

So long as it was supposed that bacteria gained 

(1) 



2 SURGICAL ASEPSIS. 

entrance to the wound principally through the at- 
mosphere, chemical disinfectants in contact with it 
were deemed necessary. Xow we know that infec- 
tion nearly always comes from contact, and the ex- 
clusion of disease-germs from the wound is more 
nearly under our control. 

^ The use of chemical disinfectants is necessary 
in the preparation for an aseptic operation, but the 
antiseptics are used before the Avound is made, and 
not in contact with it. 

The advantage of aseptic wound treatment over 
the antiseptic is very obA'ious. The more potent anti- 
septics — as bichloride of mercury, carbolic acid, and 
iodoform — may produce serious and even dangerous 
constitutional effects if used on any extensive wound 
or absorbing surface. In such strength that they are 
ei^cient as germicides they produce cellular necrosis 
of the tissues on the surface of the wound. Dr. Hal- 
sted has shown that the irrigation of fresh wounds 
with a solution of bichloride of mercury of only the 
strength of 1 to 10.000 causes a line of superficial 
necrosis which can be demonstrated under the micro- 
scope. This cellular necrosis retards the repair in 
the wound and lessens the normal resistance of the 
tissues to the action of any bacteria which may gain 
access to them, either during or subsequent to the 
operation. 

Antiseptic solutions should never be used in 
contact with serous membranes, as they favor the 
formation of adhesions. In the peritoneal cavity and 
in joints this is especially disastrous. 

Accidental wounds are usually already infected. 
In such a case the wound may be thoroughly 



GENERAL CONSIDERATIONS. 3 

washed with some. reHable antiseptic solution and 
then treated as an aseptic wound. 

While the term aseptic would imply that the 
wound is kept perfectly germ-free, the fact remains 
that the hands of the surgeon and the skin of the 
patient cannot be absolutely sterilized by any known 
method. There are also a small number of bacteria 
which gain entrance from the air. But the tissues 
of the body are capable of resisting small numbers 
of bacteria, so that septic infection and wound sup- 
puration have been almost completely banished from 
most hospitals and may be avoided in private sur- 
gical practice with equal certainty. 

There are several factors which determine the 
existence or non-existence of suppuration in a 
wound. The principal ones are the number of bac- 
teria present in the wound, the virulence of the 
organisms, the presence of fluids which may act as 
culture media for their development, and the resist- 
ance of the tissues to the niicrobic invasion. 

Watson Cheyne has shown that the number of 
bacteria introduced not only modifies the symptoms, 
but also the character, of the septicaemia. He ex- 
perimented with a pure culture of the proteus vul- 
garis injected into the muscular tissue of rabbits. 
He estimated that ^/jq cubic centimeter of a pure 
culture contained about 225,000,000 bacteria, and he 
found that this amount caused the speedy death of 
the rabbit when injected. 

A quantity of the same culture representing ^/^^ 
cubic centimeter caused only a localized abscess at 
the point of the injection and the death of the animal 
in six or eight weeks. 



4 SURGICAL ASEPSIS. 

Amounts of less than V500 cubic centimeter and 
containing 450,000 bacteria produced no results. 

When the various pus-producing organisms gain 
access to the tissues they may likewise cause simply 
an inflammation which does not disorganize the tis- 
sues and cause suppuration, or if larger numbers are 
introduced they may cause a localized suppuration, 
or they may gain access in such numbers as to cause 
a rapidly fatal result before suppuration has taken 
place. The healthy tissues can usually resist a certain 
number of pathogenic organisms of a given viru- 
lence, and it is only in a few instances that a very 
small number will produce a fatal result. 

Different varieties of bacteria vary greatly in 
the number required to produce a fatal result. One 
or two of the bacilli of anthrax injected into a rabbit 
will produce a fatal form of the disease, while it re- 
quires at least 1000 of the bacilli of tetanus, and more 
than 18,000 of the proteus vulgaris to produce the 
same result. 

Not only do the different varieties vary in their 
virulence, but the same organism may vary greatly, 
according to its source. The pyogenic organisms 
from an abscess in active development are much 
more active than are the same organisms from a 
chronic suppuration. But the virulence of an atten- 
uated organism may be increased by passing through 
this active change; so that bacteria taken from a 
chronic source of suppuration may produce only mild 
infection, while the bacteria taken from this mild, but 
acute, case may produce a virulent septicaemia. The 
colon bacillus is much more virulent when taken 
from a suppurating peritonitis than when taken from 
its normal habitat in the intestinal canal. 



GENERAL CONSIDERATIONS. 5 

Some organisms also seem capable of attacking 
only certain kinds of tissue. The gonococcus, which 
is a very virulent organism in the genital tract and 
the eye, seems almost incapable of existence in any 
other tissue unless it may possibly be in the joints. 

Intraperitoneal injections of pure cultures of 
the gonococcus into white mice or guinea-pigs cause 
a localized inflammation and suppuration, which 
rapidly subsides and the organisms die out. This 
shows that, while the organisms in large numbers 
may produce a certain amount of inflammation, they 
have httle or no power of multiplying or spreading 
in their tissues. It must be remembered that gono- 
cocci are inactive also in the genital tract of all the 
lower animals ; so that these experiments are of less 
value than they would otherwise be. But chnical ex- 
perience has shown that the gonococcus has little 
pawer of proliferation in the peritoneal cavity of the 
human subject, and, when this organism alone is 
found in cases of pyosalpinx, there is little danger of 
peritonitis. 

As has been intimated, a limitation of fluids 
which may act as culture media lessens the danger 
of sepsis. For the development of bacteria in a 
wound it is necessary that there should be both the 
seed and the soil suitable for its growth. 

Serum and blood-clot, when aided by the heat 
of the body, furnish ideal conditions for the develop- 
ment of bacteria. 

Retained fluids in a wound, besides acting as a 
culture medium, lessen, by their pressure and con- 
sequent obstruction of the capillary circulation, the 
resistance of the adjacent tissues to the action of bac- 



6 SURGICAL ASEPSIS. 

teria. Necrosed tissue from the use of clamps, re- 
tractors, strong antiseptics, or the cautery also fur- 
nishes a good soil. 

It is therefore important that clean incisions 
should be made, and the tissues should be protected 
from bruising as much as possible. 

Blunt dissection should not be employed except 
when absolutely necessary. All oozing should be 
checked and the wound be made clean and dry before 
it is closed. The same objection which has been 
made to the use of strong antiseptics may be made 
to the use of very hot compresses or the hot flushing 
which is so much used to check capillary oozing. 
These measures cause coagulation necrosis. 

Fluid at a temperature higher than 110° to 112° 
F. is certainly capable of doing much harm in the 
peritoneal cavity. After its use it may be observed 
that the serous membrane has lost its luster and it 
is much more likely to be invaded by any germs 
which may be present. 

The resistance of the tissues to the action of 
bacteria is a matter of great importance to us. As 
was shown by Cheyne in the experiments which have 
been mentioned, a considerable number of bacteria 
may be destroyed by the tissue-cells. Prof. J. G. 
Clark in the Johns Hopkins Bulletin, April, 1897, gives 
some very painstaking experiments on the tolerance 
of the peritoneum to a limited quantity of micro- 
organisms. He also found that the germs are much 
more readily eliminated by the tissues when they are 
diluted by sterile fluid which is easily taken up by 
the lymphatics. This fact, combined with the dis- 
covery of Muscatello, that fluids are principally elim- 



GENERAL CONSIDERATIONS. 7 

inated from the peritoneal cavity through the lymph- 
spaces of the diaphragmatic peritoneum, has led to 
the postural method of drainage employed by Kelly, 
of Baltimore, and later by many other surgeons. 

This consists in leaving from one to two pints 
of normal salt solution in the abdominal cavity and 
the elevation of the foot of the bed eighteen inches. 
Muscatello found that there is normally a current in 
the peritoneal cavity which carries fluids and foreign 
particles toward the diaphragm, regardless of the 
posture of the animal, although gravity greatly as- 
sists or retards this current. In dogs that were sus- 
pended with heads down, carmine bodies which had 
been introduced into the peritoneal cavity appeared 
in the retrosternal and thoracic lymph-glands in from 
five to seven minutes, while in animals in which the 
posture was reversed it was five and one-half hours 
before they could be recovered in these glands. 
Wegner also found that the peritoneal cavity of the 
dog may absorb a remarkable amount of fluid, in 
some cases amounting to from 3 to 8 per cent, of 
the bodily weight in one hour. 

The tissues dispose of bacteria when encount- 
ered in small numbers by the process of phagocy- 
tosis. In this process the leucocytes are the most 
active agents, but the fixed tissue-cells also take a 
part. The bacterium is enveloped by the cell and is 
digested by it. Cobbett and Melsome made some 
interesting observations upon the destruction of bac- 
teria in the peritoneal cavity of rabbits. After in- 
jecting 5 cubic centimeters of broth culture which 
was swimming with streptococci, they killed the 
animal in thirty hours, and found only one chain of 



8 SURGICAL ASEPSIS. 

Streptococci, but many single cocci were found en- 
veloped in leucocytes. In other animals treated in 
the same manner no active streptococci were found. 
When a larger number of the bacteria are introduced, 
the leucocytes are unable to cope with the rapidly 
multiplying germs, and suppuration or septicemia 
ensues. Aseptic animal tissue — as catgut or decal- 
cified bone — is removed after the same manner that 
the bacteria are destroyed. 

The general condition of the patient has much 
to do with the resistance of the tissues to microbic 
invasion. Especially are the subjects of organic dis- 
ease of the heart, arterial sclerosis, chronic nephritis, 
pyelitis, diabetes, and cirrhosis of the liver liable to 
septic infection. In a recent number of the Johns 
Hopkins Bulletin Dr. Simon Flexner has called special 
attention to these causes of septic infection under the 
title of ''Terminal Infections." 

From the results of Dr. Clark's experiments, 
which have been referred to. Dr. Howard A. Kelly 
draws the following conclusions : — 

1. Under normal conditions the peritoneum can 
dispose of large numbers of pyogenic organisms 
without producing peritonitis. 

2. The less the absorptive power of the peri- 
toneum, the greater is the danger of infection. 

3. Irritant chemical substances injure the tissues 
of the peritoneum, and prepare a lodging place for 
organisms which becomes the starting-point for peri- 
tonitis. 

4. Stagnation of fluids in dead spaces favors the 
production of peritonitis by furnishing a suitable cult- 
ure medium for the growth of bacteria. 



GENERAL CONSIDERATIONS. 9 

5. The association of infectious bacteria with 
blood-clots in the peritoneal cavity is especially liable 
to produce peritonitis. 

6. Traumatic injury or bruising of tissue are 
strong etiological factors in the production of sepsis 
when associated with infectious organisms. 

The fact that the tissues are capable of success- 
fully combating a limited number of bacteria should 
certainly not cause us to relax our vigilance in any 
way, but it explains why infection does not always 
follow the entrance of the bacteria which unavoid- 
ably gain access to the wound. 



CHAPTER II. 

PATHOGENIC BACTERIA. 



Inflammation in all its forms is the result of 
the action of one or more kinds of pathogenic bac- 
teria upon the tissues. 

Suppuration is caused by the presence of some 
variety of the pus-producing bacteria in such num- 
bers that the tissues are incapable of their destruc- 
tion and elimination. When present in small num- 
bers these pyogenic bacteria may give rise to a 
simple non-suppurative inflammation. When the in- 
flammation follows this fortunate course, the bacteria 
are destroyed by the leucocytes, which pass through 
the walls of the capillaries and attack the bacteria. 
Much of the swelling in the affected part is due to 
this accumulation of leucocytes in the tissues. 

When the bacteria are present in such numbers 
that the leucocytes cannot destroy them, suppuration 
ensues. 

Pus is a mixture of bacteria, leucocytes, and 
fixed tissue-cells which have been liquefied by the 
peptonizing action of the bacteria or of ferments 
produced by them. In rare cases pus, which is free 
from active micro-organisms, may be found, the 
bacteria from some cause having died out after sup- 
puration has occurred. In old cases of pyosalpinx 
it is not unusual to find the pus sterile. 
(10) 



PATHOGENIC BACTERIA. 11 

Suppuration always causes both local and sys- 
temic disturbance, but either may predominate to 
such a degree that the other is overshadowed. Lo- 
cally, it destroys the fixed tissue-cells. The systemic 
effects may be caused either by the entrance into the 
circulation of the bacteria themselves or by the tox- 
ins which are formed at the point of suppuration. 

Septic Intoxication is the poisoning- caused by 
absorption of the toxins from a localized infection 
without the entrance of bacteria into the circulation. 
When this form of infection alone is present, re- 
covery speedily follows the removal of the pus from 
the local lesion, thus cutting off the supply of the 
infecting agent. 

Bacteraemia is the blood disease caused by the 
presence and multiplication in the blood of pathog- 
enic bacteria. 

Septicaemia is that form of bactersemia in which 
pyogenic germs invade the circulatory system from 
some primary seat of infection, and multiply so 
rapidly in the blood that the patient usually dies 
within a few days. 

Pyaemia is septicaemia plus secondary abscesses, 
disseminated from an infected thrombus. It is less 
acute in its course than septicaemia, principally be- 
cause those cases which we designate septicaemia are 
so rapidly fatal that there is no opportunity for local- 
ized abscesses to form. 

There must be some gateway, or atrium, for tlie 
entrance of the germs to the tissues. The unbroken 
skin is a very effectual barrier to their entrance, but 
they may penetrate it through a hair-follicle and 
give rise to furuncle. Another common entrance is 



12 SURGICAL ASEPSIS. 

through the gastro-intestinal tract to the general 
circulation. 

Ordinarily, when a small number of bacteria 
gain entrance to the blood they are destroyed by 
the tissues without producing symptoms; but any 
trauma which is sustained may cause a localization 
of the bacteria at that point by the blood-stasis which 
the injury causes. It is in this manner, that an in- 
flammation is caused by an injury which does not 
break the skin. 

That pus-microbes are the immediate and es- 
sential cause of suppurative inflammation and pus- 
formation has been well established by clinical ob- 
servation and experimentation. Whenever the sur- 
geon divides the tissues he makes an atrium for the 
entrance of pathogenic bacteria. It is not intended, 
here, to go into the bacteriology of wound infection 
to any great degree, but it is necessary to note the 
characteristics of some of the more common pathog- 
enic organisms. 

PYOGENIC BACTERIA. 

Staphylococcus Pyogenes. — There are three varie- 
ties of this organism: the staphylococcus pyogenes 
aureus, albus, and citreus. These are the most com- 
mon bacteria which are present, either alone or with 
other varieties, in acute suppuration. Their fre- 
quency is in the order in which they are named. 
These organisms resemble each other very closely 
in appearance, with the exception of their color. 
They are spherical cocci growing irregularly in 
clusters or in masses. In culture media they grow 



PATHOGENIC BACTERIA. 13 

rapidly at ordinary room temperature, but multiply 
much more rapidly at the temperature of the body. 
They have considerable tenacity of life outside the 
body, and it requires a somewhat higher degree of 
temperature to destroy them than most other bac- 
teria which are free from spores. They are found 
almost universally distributed in Nature, being in the 
soil, on the skin, in water, and, in fact, are usually 
present on any unsterilized object. 

The staphylococcus aureus is the most virulent 
of these organisms, as well as the most frequently 
encountered. 

Staphylococcus Epidermidis Albns. — Prof. William 
H. Welch discovered this organism present in the 
deeper layers of the skin almost constantly, even 
after the most rigid sterilization. To it he attributes 
many of the stitch abscesses, although it is very often 
present in wounds which heal without suppuration. 
It is the least virulent of all the pyogenic bacteria. 
In general characteristics it resembles very closely 
the staphylococcus pyogenes albus, and by many 
bacteriologists is considered only as a variety of that 
organism. 

Streptococcus Pyogenes. — This is the organism 
which is usually found in a spreading phlegmonous 
inflammation. Under the microscope it is seen in 
chains much like a string of beads. It is not so fre- 
quently encountered as are the staphylococci, but it 
is much more virulent. It causes a rapidly spreading 
infection, and when present in suppurative peritoni- 
tis the peritoneal surface looks blistered and covered 
with patches resembling wash-leather. When this 
condition is found the case is always very serious. 



14 



SURGICAL ASEPSIS. 



Fig. I. 

Staphylococcus pyogrones aureus. 



Fig. 4. 
Bacillus coli communis. 



Fig. 2. 



Streptococcus pyogenes. 
Fig. 3. 




o^ 



Fig. 5. 

Bacillus tetani. 



Fig. G. 



m 



Gonococcus. 



Bacillus tuberculosis. 



PATHOGENIC BACTERIA. 15 

Gonococcus of Neisser. — This organism is -the 
specific cause of gonorrhoea, and has an interest to 
the surgeon principally from being often encountered 
in operations complicated with tubal disease. 

These bacteria are distinguished by occurring 
in clusters, within pus-corpuscles. They are very 
virulent when brought in contact with the mucous 
surfaces of the genito-urinary tract, but are difficult 
to cultivate outside the body, and have very little 
virulence when introduced into the peritoneum or 
connective tissue. 

Its virulence is so slight here that Dr. Kelly has 
abandoned drainage of the abdominal cavity when 
the microscope reveals only gonococci in the pus 
which is encountered. 

Bactermm Coli Commune. — This bacillus is always 
present in the intestinal canal. Usually in conjunc- 
tion with the staphylococcus or streptococcus pyog- 
enes it is present in appendical and ischio-rectal ab- 
scesses. It may also appear in organs remote from 
the intestinal tract. It is a frequent factor in sup- 
purative inflammation of the gall-bladder. It is this 
organism which gives the characteristic faecal odor 
which is commonly observed in appendical abscesses. 
As the organism is of very slight virulence as com- 
pared with the other pus-producing bacteria, this 
odor is not an unfavorable sign. In shape this bacil- 
lus is a rod with rounded ends, sometimes so short as 
to appear almost spherical and again it may be much 
longer. 



16 SURGICAL ASEPSIS. 

NON=PYOGENIC BACTERIA. 

In addition to the bacteria which may produce 
suppuration in a wound there are many which are 
capable of producing serious disturbance or a fatal 
result, even though the wound may heal promptly. 
These bacteria poison the system principally by the 
toxins which are formed at the site of the wound 
and are rapidly taken into the general circulation. 
Bacteria themselves may also be often demonstrated 
in the blood and in organs distant from the original 
entrance of the organisms. 

Streptococcus Erysipelatosus. — This organism is 
the essential cause of erysipelas, which was the bane 
of the older surgeons. This streptococcus invades 
the superficial lymphatic channels of the skin ex- 
clusively. They appear under the microscope to be 
identical with the streptococcus pyogenes, and are now 
regarded as being the same by nearly all bacteriolo- 
gists. From a clinical standpoint there is abundant 
proof that erysipelas is caused by its own specific 
organism, which is so nearly identical with the strep- 
tococcus pyogenes in its staining properties, cultural 
characteristics, and appearance under the microscope 
that it cannot be differentiated. 

Bacillus ' Tetani. — This bacillus is not so com- 
monly encountered as most other forms, but owing 
to its extreme virulence it is of great interest to the 
surgeon. It is usually found in the soil and in the 
excreta of the domestic animals. It is anaerobic, or 
incapable of multiplying in the presence of oxygen. 

The bacilli may retain their vitality, however, 
for several months in the open air and will take on 



PATHOGENIC BACTERIA. IT 

active development as soon as favorable conditions 
are presented. They are most likely to develop in 
accidental punctured wounds of the hands and feet. 
Wounds in these situations are most likely to come 
in contact with soil, and punctured wounds which do 
not allow the entrance of air are favorable for the 
development of this bacillus. 

The bacilli appear under the microscope as 
slender rods, and at the temperature of the body 
they multiply by the formation of spores at one end 
of the rod, giving it the appearance of a pin or drum- 
stick. This property of spore-formation by the bacil- 
lus is of practical importance, as the spores are more 
resistant to the ordinary means of sterilization than 
are the bacteria. The spores are not destroyed by a 
temperature of 165° F. in an hour. They will also 
resist the action of a solution of bichloride of mer- 
cury 1 to 1000 for three hours and a 5-per-cent. solu- 
tion of carbolic acid for ten hours. To insure 
their destruction by steam sterilization the fractional 
method should be used. They are destroyed by boil- 
ing water in three to five minutes. 

Bacillus of Tuberculosis. — This bacillus is the 
smallest of the bacteria which are pathogenic to man. 
It is a slender rod which varies in length, being from 
one-fourth to three-fourths the diameter of a red 
blood-corpuscle. Under the microscope it is prin- 
cipally distinguished by its peculiar staining proper- 
ties. 

Tubercle bacilli have considerable power of re- 
sistance to external influences, and can retain their 
vitality outside the body for a long time. Dried 

2 



18 SURGICAL ASEPSIS. 

Sputum has been found to contain active bacilli after 
two months. 

From the prevalence of pulmo.nary tuberculosis 
and the usual carelessness in the disposal of sputa, 
the germs must be widely distributed. 

We would expect that wounds would be more 
commonly infected by this organism than we find 
them to be. 

The tissues of most healthy persons are resistant 
to these germs, and Volkmann stated, several years 
ago, that tubercular infection never follows any ex- 
tensive trauma, but often does follow slight injuries 
or contusions. He explained this by assuming that 
the active tissue changes which accompany any se- 
vere traumatism prevents the infection. Since the 
phagocytic action of the leucocytes has been demon- 
strated, this action can be easily understood. It is 
probably by this determination of leucocytes to the 
seat of injury that cases of tubercular peritonitis are 
cured by simply opening the abdomen. 

The baciUi develop, under certain conditions, by 
the formation of spores, and these resist the ordinary 
method of sterilization and require the fractional 
method. The bacillus of tuberculosis is not a pus- 
producing organism, and the contents of a tubercu- 
lar, or cold, abscess is not true pus unless accident- 
ally infected by some of the pyogenic bacteria. 

These tubercular abscesses, to prevent second- 
ary infection, should be opened under aseptic pre- 
cautions. 

There are several other pathogenic organisms 
by which wounds are sometimes infected, but these 
already mentioned are the more common ones, and 



PATHOGENIC BACTERIA. 19 

the same means which are employed for their de- 
struction will destroy all others. 

Many varieties of bacteria, which may be dem- 
onstrated under the microscope, are harmless to 
the human organism. 



CHAPTER III. 

SOURCES OF INFECTION. 



In the avoidance of infection it is necessary to 
know every avenue by which bacteria may gain en- 
trance to the wound. 

The ways in which they may do this are by the 
air, the hands of the surgeon or skin of the patient, 
the surgeon's instruments, by the fluids introduced 
into the wound, by sponges, by sutures and hgatures, 
and by the dressings. 

This statement presupposes a wound through 
healthy tissues. The wound may be infected by any 
of the pathogenic organisms which are already pres- 
ent in the tissues. 

Air Infection. — It was formerly supposed that 
the principal source of wound infection was by air 
contamination, and it was a2:ainst this source of in- 
fection that Listerism was directed. It has been 
found that the air contains very few micro-organ- 
isms, and that these are almost entirely associated 
with the dry dust floating in it. 

The essential conditions for the growth of bac- 
teria — warmth, moisture, and a nutrient medium — 
are not present in the atmosphere. Only transitorily 
and in comparatively small numbers do they gain ac- 
cess to it from the warm, moist, and organic material 
of the earth's surface. Stern has shown that, after 
the artificial dissemination of bacteria in the air of a 
(20) 



SOURCES OF INFECTION. 21 

room, they gravitate to the surface by their weight, 
and that in half an hour the air is practically germ- 
free. They can float in the atmosphere only in a dry 
state, and cannot rise from a moist surface. Any 
liquid which is loaded with bacteria and even foetid 
from the products of decomposition cannot give off 
any bacteria to the air. Only the gaseous products 
of bacterial action can arise from a moist surface. 

Tyndall discovered several years ago (and it 
has since been confirmed by numerous bacteriolo- 
gists) that the breath is entirely free from germs. 
This must be qualified by the statement that particles 
of mucus or other solid matter which may be car- 
ried with the breath may carry bacteria. In a clean 
room, which is free from dust, air infection may be 
entirely ignored. It has been estimated that there 
are more than a thousand times as many germs in a 
single drop of pus than are ordinarily present in a 
cubic yard of the atmosphere. 

Water Infection. — Almost every wound, whether 
accidental or made by design of the surgeon, comes 
in contact with water. If it is accidental, it is 
"cleansed" by the patient or his friends. When 
made by the surgeon it is sponged or irrigated. It, 
therefore, is of. great interest to us to know what 
organisms water may contain. 

Bacteria are always present in water from all 
sources. Even rain-water is not germ-free, as it col- 
lects a certain number, in its descent, from the dust 
floating in the air. 

Water which contains organic material is an 
ideal culture medium for bacteria, especially if the 
temperature is favorable. It is the collection of bac- 



22 SURGICAL ASEPSIS. 

teria which causes the greenish collection on the sur- 
face of stagnant pools, and the slimy deposit on the 
sides of vessels in which water has been left standing 
for some time. 

In addition to being a good culture medium, in 
the course of its percolation through the soil it 
gathers some of the bacteria which are always abun- 
dant in the earth. 

Water, in most of our large cities, is taken from 
some large river which is a receptacle for number- 
less millions of bacteria from the drainage of other 
towns on its banks. Even if the original supply is 
reasonably pure, the water is usually stored in a 
reservoir, in which all the conditions favorable for 
the development of bacteria are present. 

In country places the supply is most often from 
a well. This is usually situated in close proximity 
to the dwelling and also often near the stable. Very 
few wells in the country are free from contamination 
by drainage from the soil. 

The investigations at the Hygienic Institute of 
Berlin estimated that the water of the river Spree 
contained an average of 37,525 bacteria per cubic 
centimeter, giving an average of 2500 to every drop 
of water. When we consider that the air of the 
hospitals, situated upon the bank of that river, ac- 
cording to the estimate of the same observers, con- 
tains only about 3000 bacteria per cubic meter, the 
comparison between air and water infection becomes 
very marked. According to these estimates, a cubic 
meter of this water would contain about 12,500,000 
times as many bacteria as would the same volume of 
air. 



SOURCES OF INFECTION. 23 

Infection by Contact. — In the pre-antiseptic 
period the most common carriers of infection were 
the hands or instruments of the surgeon, the sponges, 
and the dressings. So long as suppuration and its 
frequently resulting septicaemia or pyaemia were en- 
countered, they were considered to be the legitimate 
results of any wound, as suppuration was supposed 
to be the natural method for the repair of wounds. 
But occasionally an epidemic of erysipelas or gan- 
grene of such magnitude as to require the closing of 
the hospital would occur. These epidemics were 
supposed to arise from the vitiated air of the hospital. 
Such was not the case, but the germs of infection 
were carried from patient to patient by the unsteril- 
ized instruments or by the hands of the surgeon or 
his dresser. 

Instruments which are incapable of being per- 
fectly cleansed of blood or shreds of tissue are excel- 
lent harbors for the lodgment and multiplication of 
germs. 

The hands of the surgeon and the skin of the 
patient are constantly the habitat of a number of va- 
rieties of bacteria, and especially of those which pro- 
duce suppuration. 

The ordinary unsterilized gauze or cotton dress- 
ing contains many bacteria, and even the commonly 
used iodoform gauze is not free from them. Liga- 
tures and sutures are important as carriers of infec- 
tion. They are buried in the depths of the wound, 
and any bacteria which they carry in their meshes 
find conditions favorable for a rapid development. 
All kinds of sutures and ligatures may be readily 
sterilized except the absorbable ones. 



24 SURGICAL ASEPSIS. 

Until very recently no method had been found 
by which these could be sterilized with certainty with- 
out disintegration of the ligatures. Being of organic 
material, they furnished an excellent pabulum for the 
support of bacteria. At the present time methods 
are so wxll perfected for the sterihzation and preser- 
vation of absorbable sutures and ligatures that they 
may be used with perfect safety. 



CHAPTER IV. 

MEANS OF STERILIZATION. 



By sterilization we mean the process of render- 
ing an object completely free from living organisms. 
Means which we may adopt with advantage for the 
sterilization of some articles are unsuitable for others. 
According to the individual conditions, one steril- 
izing procedure is to be preferred at one time, and 
some other at another time. 

Very frequently a single method of sterilization 
does not suffice, and we are required to use several 
together or in succession. In the selection of the 
method of disinfection we must consider: — 

1. The composition of the object to be disin- 
fected and its liability to injury by the disinfecting 
agent. 

2. The resistance of the organisms to be de- 
stroyed. 

3. The disinfecting power of the agent to be 
applied. 

4. The resistance which may be opposed to the 
disinfecting agent by the form of the object, by layers 
of fat or dirt which may envelop it, or by chemical 
changes which its contact with the disinfectant will 
cause. 

The means at our disposal for the removal of 
bacteria are : — 

(25) 



26 SURGICAL ASEPSIS. 

1. Mechanical removal by washing and scrub- 
bing. 

2. Destruction by heat. 

3. Destruction by chemical germicides. 

Of these means, the first mentioned easily stands 
first in importance, and some eminent surgeons, in- 
cluding Lawson Tait, claim to use no further means 
of disinfection. It occurs, however, that Tait washed 
his own hands and the field of operation with oil of 
turpentine, which is a most excellent germicide. 

WASHING AND SCRUBBING. 

Simple cleansing is the preparatory step in every 
disinfection, and scrupulous cleanliness in surgical 
practice is our most important resource in the avoid- 
ance of infection. Everything which can be washed 
should be made scrupulously clean by soap and 
water. Especially does this apply to the hands of 
the surgeon, the field of operation, all instruments, 
trays, basins, pitchers, operating gowns, etc. 

In this process of scrubbing soap plays an im- 
portant part by softening the epidermis and dissolv- 
ing the fats. One should be selected which contains 
enough alkali to dissolve the fats from the skin. This 
solvent action may be increased by the addition of 
alcohol or ether to the soap. 

Ordinary soaps are not germicidal, but in strong 
solutions they inhibit the multiplication of bacteria. 
Some soaps are made germicidal by the addition of 
antiseptics. 

Tincture of green soap is usually advised for 
skin disinfection, and it may well be relied upon. It 



MEANS OF STERILIZATION. 27 

is a strong potash soap with about 30 per cent, of 
alcohol added. 

The ethereal antiseptic soap made by Parke, 
Davis & Co. is especially adapted to the cleansing 
of the skin, as the ether dissolves the fat from the 
cuticle and allows the chemical disinfectants which 
follow to penetrate more deeply. 

Among the germicidal soaps, synol, made by 
Johnson & Johnson; and McClintock's germicidal 
soap, made by Parke, Davis & Co., are the most re- 
liable. Their value, as germicides, has been demon- 
strated in 1- and 2-per-cent. solutions. In actual use, 
the strength of solution in which the soap will be 
used will be very indefinite. . 

Synol is claimed by its makers to depend for its 
germicidal action upon the cresol bases, combined 
with a pure alkaline soap. It has been tested both 
clinically and in the laboratory by Dr. A. H. Goelet, 
of New York, and he uses no other means of skin 
disinfection. He has found that, after five minutes' 
scrubbing by nail brush, with synol, the scrapings 
from the hands show them to be free from germs. 

McClintock's germicidal soap is intended rather 
as a germicide than as a soap, but is put up in cakes 
for convenience and for the auxiliary effect of the 
saponaceous material upon the mercuric salt which 
it contains. The soap contains 2 per cent, of mer- 
curic iodide, and a 1-per-cent. solution of the soap 
would contain iodide of mercury in the strength of 
1 to 5000. 

Dr. McClintock claims that a 1-per-cent. solu- 
tion of this soap is equivalent in germicidal power to 
a solution of bichloride of mercury of a strength of 



28 SURGICAL ASEPSIS. 

1 to 1000. This soap has no corrosive action on 
metals and does not coagulate albumin. The author 
has used this preparation and has been well satisfied 
with cHnical results. If used repeatedly, it is quite 
irritating to the skin of some persons. Were it not 
for this objection it would be a valuable addition to 
the resources of the surgeon. 

In routine work, disinfecting the skin by simple 
scrubbing with soap and water, to be followed by 
some reliable antiseptic, is to be preferred to the 
combination of antiseptics with the soap. 

In emergency cases, or where an elaborate tech- 
nique is impossible, the germicidal soaps may be 
used. 

HEAT. 

Heat, in the various ways we employ it, is the 
most certainly destructive to germs of any means at 
our command. This method of sterilization should 
be applied to every object which is not injured by its 
action. The methods of using heat as a disinfectant 
are the actual flame, dry heat, steam, and boiling 
water. 

The flame is very seldom used for sterilization, 
but, if other means are not at hand, it may be used 
for the disinfection of probes, needles of hypodermic 
syringes, and other small instruments. It draws the 
temper of steel instruments. 

Dry heat is not so efficient as is steam for steril- 
ization, and it requires special apparatus for its use. 
It is seldom used as a disinfectant, and it would better 
be discarded altogether. It requires an exposure of 
one hour and a half, at 212° F., of dry heat to destroy 



MEANS OF STERILIZATION. 29 

the pyogenic bacteria, while they are destroyed in 
twenty minutes by steam at the same temperature. 

BoiHng water is the most potent of any form 
of heat and should always be used when possible. 
Ordinary bacteria are destroyed by boiling water in 
from three to five seconds, and anthrax spores, which 
are the most virulent in form, in about two minutes. 
Boiling water may be used for the sterilization of 
nearly all instruments, small basins, silk, silk-worm, 
or silver sutures, and when a sterilizer is not at hand 
gauze sponges may be disinfected by boiling. 

Steam, at a temperature of 212° F., is equally 
as effective as boiling water for the destruction of 
germs, although it does not act as rapidly. When 
used under pressure, the temperature may be raised 
much above the boiling point of water and its ger- 
micidal action is greatly hastened. It has also been 
found that most organisms, which do not contain 
spores, can be destroyed by a prolonged exposure 
to steam much below the boiling point of water. A 
temperature of 145° F. is sufficient to kill most bac- 
teria in two hours, according to Pasteur and Tyndall. 

Steam, at 212° F., is destructive to all ordinary 
bacteria in fifteen or twenty minutes, if they are 
freely exposed to its action. It is also necessary 
that the steam should be saturated ; that is, unmixed 
with air. 

Much has been said about the relative value of 
live steam, or steam in circulation, and steam at rest. 
One is as effectual as the other when it comes in 
contact with the bacteria, but live steam penetrates 
packages much more quickly and so lessens the time 
required for the process. 



30 



SURGICAL ASEPSIS. 



For the effective use of steam, as a sterilizing" 
agent, it is desirable to have an apparatus which will 
force a good volume of live steam into the sterilizing 
chamber, and that the temperature in this chamber 




Fig. 7. — High-Pressure Steam Sterilizer Manufactured by 
Truax, Greene & Co. 

should be maintained at a temperature of at least 
212° F. 

There are three classes of sterilizers : The high 
pressure, the understeam, and the oversteam. The 
high-pressure sterilizers are not portable and are ex- 
pensive; so they are used only in hospitals and pri- 



MEANS OF STERILIZATION. 31 

vate operating rooms. Truax, Greene & Co., of 
Chicago, and the Kny-Scheerer Company, of New 
York, make some very elaborate steriHzers of this 
variety. With these instruments at a temperature 
of 230° F. and a pressure of 5 pounds to the square 
inch all the pathogenic bacteria excepting those 
which carry spores may be destroyed with certainty 
in five minutes. 




Fig. 8. — Sectional View of Arnold Sterilizer. 

The understeam and oversteam sterilizers are 
intended to maintain a temperature of 212° F., and 
must be so constructed that a good volume of steam 
is constantly forced into the sterilizing chamber un- 
der moderate pressure, and this chamber must be 
surrounded by a jacket to prevent cooling and con- 
densation at its sides. 

The understeam sterilizers are so constructed 
that the current of steam enters the sterilizing cham- 



32 



SURGICAL ASEPSIS. 



ber at the bottom, passes upward through or around 
the articles to be sterihzed, and escapes at the top. 
As air has a higher specific gravity than steam, it 
is difficult to force it from an understeam steriHzer. 
The steam as fast as generated passes upward 
through the overlying air, carrying only a small por- 
tion with it as it escapes at the top. The air, being 




Fig. 9. — View of Parts of Arnold Sterilizer. 



heavier, naturally seeks a lower level, and results in 
an admixture of the two, the upper portion being 
principally steam, while the lower portion is prin- 
cipally heated air, carrying very little moisture and 
consequently of much less germicidal power. After 
a time the air is nearly all expelled from the steriUz- 
ing chamber, but the period of exposure must be 
extended to allow for this, and if any understeam 



MEANS OF STERILIZATION. 



33 



sterilizer is used the sterilization should be not less 
than forty-five minutes. The best known of the un- 
dersteam sterilizers is the Arnold, made by Wilmot 
Castle & Co., of Rochester, N. Y. It has a device 
by which only a small amount of water passes from 
a reservoir into a shallow compartment underneath, 
to which heat is applied. 

As there is only a small amount of water to boil 
at a time, it is converted into steam very rapidly and 




Fig. 10.— Collapsing Sterilizer Ready for Use. 



rises through a funnel, in the center, into the steriliz- 
ing chamber above. The excess of steam escapes 
about the cover and forms a steam jacket under the 
hood, which envelops the sterilizing chamber. 

The objections to this sterilizer are that it is un- 
wieldy and noisy to carry about, the solder about 
the boihng chamber is liable to melt out even with 
great care, and it is very difficult to repair. 

The first of these objections has been overcome, 
to some extent, by making the sterilizer of a rectan- 



34 SURGICAL ASEPSIS. 

gular shape, so that it may be carried in a suitable 
carrying case. 

The Wilmot Castle Company also make a col- 
lapsing sterilizer, intended for physicians who oper- 
ate in private houses. It is very compact, and may 
be carried in an extension case which is made for it. 
This sterilizer is so small that it must be filled several 
times to sterilize all the articles necessary for a major 
operation. It has no jacket surrounding the steril- 
izing chamber, so the temperature maintained is 
somewhat below 212° F., and the period of steriliza- 
tion must be lengthened to at least an hour. 




Fig. 11. — Collapsing Sterilizer Closed. 

Oversteam sterilizers are so constructed that 
the steam current enters the steriHzing chamber at 
or near the top, and escapes wholly or in great part 
through openings near the bottom. As steam is 
lighter than air it collects in the upper portion of 
the chamber, and can find means for escape only by 
forcing the air downward and out of the sterilizing 
chamber. The pressure required to force the air 
from the sterilizer insures the penetration by steam 
of the articles to be sterilized, regardless of the man- 
ner of wrapping or packing. 

One of the best types of oversteam sterilizers 



MEANS OF STERILIZATION. 35 

is the Boeckmann (Fig. 35). It consists of two cyl- 
inders; the inner one, which constitutes the steriHz- 
ing chamber, is inverted, while the outer one, which 
is about an inch larger in diameter, covers the first, 
acting as a hood. The steam enters the space be- 
tween the two cyHnders and can enter the inner cyl- 
inder only at the top, and escapes through an open- 
ing at the bottom. 

I have had made for myself a very simple, 
roomy, and cheap sterilizer for office use. It is 
made of galvanized iron, but can be made of tin or 
copper. It consists, first, of a simple box, 16 by 
16 by 20 inches in size. This box is provided with 
a well-fitting cover. Inside this is another box, 14 
by 14 by 18 inches in size. This is also supplied with 
a closely-fitting cover. The bottom of this box is 
placed about 3 inches above its base, and the cor- 
ners are clipped from the sheet of iron which forms 
this partition, so that it forms an opening at each 
corner of the box through which steam may enter 
the sterilizing chamber. This is carried nearly to 
the top of the chamber by soldering a strip of metal 
into the angle of the box in such a manner that it 
makes a flue to conduct the steam. It escapes prin- 
cipally through some openings near the base of the 
sterilizing chamber. 

When in use the outer box is filled with water 
to the depth of one or two inches, and then the inner 
box is placed within it. All the steam which is gen- 
erated inside the base of the inner box, or from a 
surface 14 by 18 inches in area, must pass through 
the sterilizing chamber and it then escapes through 
openings near the base, into the outer box. This 



36 



SURGICAL ASEPSIS. 



insures a good supply of live steam constantly in the 
sterilizing chamber, and the steam escaping from the 
inner box fills the space between this and the outer 
box, and maintains the heat at 212° F. 




Fig. 12. — Authoi-'s Sterilizer. 



The only possible objection which can be made 
to this sterilizer is that it has no double bottom for 
the rapid generation of steam. This is nearly com- 
pensated for by the very large heating surface, and 
if it is filled with hot water there is very httle delay. 



MEANS OF STERILIZATION. 87 

THI extreme simplicity of the apparatus and the ease 
with which it may be repaired, if it should boil dry, 
are points in its favor. It is not easily portable, 
although one of moderate size might be carried in 
an extension case. 

At times an operation must be performed when 
it is impossible to secure a sterilizer. Then an ordi- 
nary steam cooker may be used, or a wash-boiler with 
a few inches of water at the bottom and the packages 
lying upon a clean board supported above the water 
by two bricks. It is safe to assume that a tempera- 
ture of 1G0° F. may be secured in this way, and ac- 
cording to the statements of Pasteur and Tyndall, 
already cited, this temperature is sufficient to destroy 
germs, but the sterilization must be continued for one 
and one-half to two hours. 

As has been already stated, a temperature of 
2.12° F. is destructive to all active or vegetative forms 
of bacteria in from fifteen to twenty minutes. But 
when dressings, towels, etc., are rolled in packages, 
this temperature is not reached in the deeper parts 
of the package for several minutes. Therefore the 
packages should remain in the sterilizer for at least 
forty-five minutes. 

If the packages are thoroughly warmed before 
being put in the sterilizer, the steam will not con- 
dense upon their surfaces and wet the packages. 
When removed from the sterilizer they will dry at 
ordinary room temperature if this precaution has 
been taken. 

Spore-forming bacteria will resist the action of 
steam, for a long time, at a temperature of 212° F. 
Most of the spore-forming bacteria are non-pathog- 



38 SURGICAL ASEPSIS. 

enic, but those of tetanus and tuberculosis are notable 
exceptions. 

All spore-forming bacteria may be destroyed 
with certainty by the fractional method of steriliza- 
tion. By this method the material to be sterilized 
is exposed to the action of steam for an hour each 
day, for two or three consecutive days. The active 
or vegetative germs are destroyed at the first ex- 
posure. The spores, which are only larval forms of 
the bacteria, are developed by the heat into the active 
form and will be destroyed by the subsequent ex- 
posures. 

This fractional method of sterilization is often 
impossible in private surgical practice, but when pos- 
sible it should be used for all material which is to be 
left permanently in the wound. Silk, which is to be 
used for ligatures or buried sutures, gauze for drains, 
etc., may be kept sterilized, and then again sterilized 
with the dressings at the time of operation. 

Formerly, it was believed that cold was destruc- 
tive to bacteria, and especially was ice supposed to be 
free from germs. Most bacteria cannot multiply ex- 
cepting at a temperature above 60° or 65° F., but 
even extreme cold is not destructive to them, and 
they take on an active form as soon as favorable 
conditions are restored. MacFadyen reports, in the 
London Lancet, Ma^vch 24:, 1900, that he tested ten 
organisms, including those of typhoid, diphtheria, 
cholera, and the bacillus coli commune and staphy- 
lococcus aureus. He exposed them to liquid air at 
a temperature of — 360° F. These organisfns re- 
tained their characteristics, and those that were vir- 
ulent before were quite as virulent afterward. 



MEANS OF STERILIZATION. 39 

CHEMICAL DISINFECTANTS. 

Since the introduction of carbolic acid as a 
germicide, by Lister, chemical disinfection has been 
constantly used in surgical practice. Various chem- 
icals have been regarded as certainly destructive to 
all germ-life, and, in the absence of any reliable cri- 
teria to demonstrate their efficiency, too much reli- 
ance has been placed on this method of disinfection. 

Germs which are present in dirt or enveloped 
in fat are almost entirely protected from the action 
of germicides in aqueous solution. 

Koch demonstrated that the strongest anti- 
septics dissolved in oil are ineffectual for the de- 
struction of germs in a moist state, because the oil 
does not penetrate the organisms. Conversely, silk 
threads impregnated with pus-germs and then im- 
mersed in oil may be laid for weeks in a watery 
solution of mercuric chloride or of carbolic acid 
without destroying the germs. Especially upon the 
surface of the body and mucous membranes are the 
organisms protected by layers of fat; so that me- 
chanical cleansing and the use of solvents for this 
fat is an important preliminary measure to precede 
the chemical disinfection. 

None of the chemical antiseptics are capable 
of instantly destroying bacteria, but must remain in 
contact with them for some time. 

Some of the agents, which we have implicitly 
trusted for years, do not kill the germs even after 
prolonged contact, but merely inhibit their action. 
This is especially true of iodoform. 

Geppert has demonstrated that our most com- 



40 SURGICAL ASEPSIS. 

monly used chemical disinfectant, bichloride of mer- 
cury, in solution of 1 to 1000 does not destroy the 
staphylococcus pyogenes with certainty in ten or 
even in fifteen minutes. 

For the sterilization of objects, which from 
their size or -shape it is impossible to subject to the 
action of heat, or from their structure would be in- 
jured or destroyed by its action, it is necessary to 
make use of chemical disinfectants. They should 
be regarded as supplemental, rather than as the 
principal agents at our disposal. 

The ideal chemical disinfectant would be one 
that might be used for a variety of purposes, readily 
soluble in water, active in germicidal properties, not 
decomposed by contact with organic matter, inex- 
pensive, and free from very objectionable odor. One 
possessing all these properties we do not have. 

Of the many chemical substances, which in 
various degrees are destructive or inhibitory to the 
action of germs, only a few need be considered in 
detail. 

It is better to employ a few antiseptics, which 
have been demonstrated by bacteriological experi- 
ments to be efificient, rather than to make clinical 
experiments in the use of new preparations at the 
peril of the patient. 

Some of the chemicals here mentioned are not 
recommended, but are considered because they are 
very generally used, and their antiseptic power is 
assumed and not proven. These chemicals should 
not be used to the exclusion of those which have 
been demonstrated to be effective germicides, un- 



MEANS OF STERILIZATION. 41 

less from the nature of the tissues- they would be 
injured by the stronger antiseptics. 

Bichloride of Mercury combines more of the 
qualities of an ideal disinfectant than any other 
chemical. It is colorless, odorless, does not injure 
any fabric or material, under most circumstances 
it is a reliable germicide, and it is inexpensive. On 
account of its corrosive action upon metals it can- 
not be used for the disinfection of instruments or 
tin basins. Granite ironware is not injured by it. 
Its power as a germicide has, however, been greatly 
overestimated. Its reputation as an antiseptic was 
due, in great part, to the original investigations of 
Koch. He asserted that a single application of it 
for but a few minutes, without any previous prepa- 
ration of the objects to be disinfected, guaranteed 
an absolute disinfection, even in the presence of the 
most resistant organisms. 

Geppert first showed the error made in these 
early experiments, and he has been followed by 
Abbott, Prudden, and many others. It is now well 
settled that bichloride solution of the strength of 
1 in 1000 does not always kill pathogenic bacteria 
in ten or fifteen minutes, and that it takes twenty- 
four hours for a solution of the same strength to 
kill anthrax spores. 

The solution has no action upon fats, and can- 
not come in contact with germs which are in the 
deeper layers of the skin and are enveloped in the 
products of the sweat-glands. 

A solution of the strength of 1 to 1000 is the 
standard solution to be used in the disinfection of 
basins, tables, and hands. The skin of some per- 



42 SURGICAL ASEPSIS. 

sons is susceptible to the action of the solution of 
this strength, and then it may be used in solution 
of 1 to 2000. 

The period of immersion must be proportion- 
ately increased if this strength is used. In the pres- 
ence of albuminous substances bichloride of mercury 
is decomposed and forms the inert albuminate of 
mercury, and the antiseptic power of the solution 
is diminished in proportion to the amount of these 
substances present. A solution which contains much 
blood is almost entirely inert. 

Oxycyanide of Mercury, according to the experi- 
ments of Deguy {Journal des Praticiens, November 
3, 1900), has the same germicidal power as the bi- 
chloride, and may be used in solutions of the same 
strength, as a substitute for the latter salt. If other 
observations should confirm his statement it would 
be a valuable substitute, as it does not corrode metal 
instruments and is not so irritating to the skin as 
is the bichloride. 

Carbolic Acid is a mild escharotic, disinfectant, 
and deodorizer. 

It is soluble in water up to 5 per cent., and it 
is usually used in this strength as a disinfectant in 
surgical practice. A 5-per-cent. solution is much 
less active as a germicide than is a 1 to 1000 solu- 
tion of bichloride of mercury. It requires about five 
days for the former to destroy anthrax spores, while 
the latter is destructive to them in twenty-four hours. 
For ordinary pus-producing bacteria, an exposure of 
at least two or three hours to a 5-per-cent. solution 
is necessary to insure their destruction. 

About the only use for carbolic acid, in aseptic 



MEANS OF STERILIZATION. 43 

surgical work, is for the disinfection of cutting in- 
struments, the temper of which is injured by re- 
peated steriHzation by heat, and which are corroded 
by mercuric solutions. That the sterilization may 
be certain the instruments must remain in the solu- 
tion at least three hours; so other means are prefer- 
able to this. 

Dr. Seneca Powell discovered that the escha- 
rotic action of carbolic acid could be prevented by 
the immediate application of alcohol. The germi- 
cidal power of each of these antiseptics is lessened 
by the association. Dr. Powell often proves to his 
class the antidotal power of alcohol by bathing his 
hands first with 95-per-cent. carbolic acid and then 
with alcohol. 

A limited pus-cavity may often be disinfected 
by this means. The cavity should first be thoroughly 
washed, then dried by dry sponging. Carbolic acid 
of a strength of 95 per cent, may be applied to every 
part of the surface and followed by alcohol. Phelps, 
of New York, reports excellent success from the 
treatment of suppurating joints after this plan. 

The treatment of infected wounds and suppu- 
rating joints by pure carbolic acid and alcohol, after 
the method of Powell and Phelps, was discussed at 
the Congress of the German Surgical Association 
held at Berlin in April, 1901. Professors Bruns and 
Honsell, of Tubingen, stated that by numerous ex- 
periments they had proven that its bactericidal ac- 
tion, when dealing with tissues containing albumin, 
is greater than that of solutions of mercuric chloride. 

Dilute solutions of carbolic acid when applied 
for several hours may produce gangrene and slough- 



44 SURGICAL ASEPSIS. 

ing of the tissues. This is especially true when ap- 
plied to the extremities. 

Dr. F. B. Harrington, of Boston, has collected 
one hundred and thirty-two cases of gangrene from 
application of dilute solutions of carbolic acid. His 
statement, that the condition is probably much more 
frequent than these figures would indicate, is true. 
The author has seen gangrene of the finger, in two 
instances, from application of 5-per-cent. solution of 
carbolic acid to a small wound. 

Alcohol has been regarded as an efiicient ger- 
micide, and has been extensively used in the disin- 
fection of the skin. Geppert found that anthrax 
spores resist its action for at least thirty days. It 
inhibits the action of ordinary bacteria, but it is not 
destructive to them except upon prolonged contact. 
Its chief value in skin disinfection is in removing the 
fat, so that the after-coming antiseptics may be more 
effective. It should, therefore, precede the use of the 
antiseptics, and should rank as does soap and water : 
a mechanical aid in the process of disinfection. It 
is usually employed for the disinfection of knives, 
but other methods are more reliable. 

Potassium Permanganate is an excellent germi- 
cide. It acts by the oxidation of organic matter and 
can attack bacteria when other watery solutions do 
not reach them. 

While having very little odor of itself, it is a 
most powerful deodorizer. Its oxidizing power is 
so great that a marine sponge, if left in a saturated 
solution for half an hour, is almost completely de- 
stroyed. It leaves a deep mahogany stain, and can- 
not be generally used on that account. This stain is 



MEANS OF STERILIZATION. 45 

completely removed in a short time by the action of 
a saturated solution of oxalic acid. 

The use of permanganate of potassium is almost 
entirely in the disinfection of the skin. It is admi- 
rably adapted to this, as it oxidizes all the organic 
matter which cannot be reached by scrubbing or by 
the use of other aqueous solutions. It should be 
used in a saturated solution, which is about 1 to 16. 

Oxalic Acid is used for- the bleaching of the skin 
after the use of potassium permanganate. Dr. Mary 
Sherwood has found, by various experiments, that 
it has a very marked germicidal power of its own. 

The slight efTervescence which comes from its 
chemical union with the potassium permanganate 
carries the chemiicals deeply into the skin and gen- 
erates considerable heat. It is soluble in about 9 
parts of water and may be used in solutions varying 
from 8 to 10 per cent. 

Chlorine is a strong germicide, ranking, accord- 
ing to Schimmelbusch, among the first class. Some 
surgeons use it for skin disinfection. It is obtained 
by mixing equal parts of commercial chloride of 
lime and sodium carbonate. This is sufficiently 
moistened to make a smooth paste, and is thor- 
oughly rubbed over the surface to be disinfected. 
The germicidal effect is from the chlorine gas which 
is set free. It has a very penetrating and disagree- 
able odor, which may be removed from the hands 
by a dilute solution of ammonia water. 

Formaldehyde is one of the newer antiseptics 
which has stood the tests of both laboratory experi- 
ments and clinical experience. Formaldehyde is a 
pungent gas, obtained by the oxidation of wood 



46 SURGICAL ASEPSIS. 

alcohol. It is soluble in water, and a 40-per-cent. 
solution is sold under the name of formalin, and this 
is the preparation now most used. It also may be 
obtained in solid form as paraldehyde. 

The gas is non-toxic and is not corrosive to 
metals. For the gaseous disinfection of rooms it is 
the most effective agent that we possess. As a re- 
sult, in great part, of the experiments of Prof. F. C. 
Robinson, of Bowdoin College, it has superseded 
nearly all the other methods of room disinfection 
after contagious diseases. His experiments show 
that bacteria, which are not more resistant than the 
bacilli of diphtheria and colon, are destroyed by the 
vaporization of 500 grammes (about 16 ounces) of 
formalin to each 1000 cubic feet of room space. 
Tubercle bacilli were not destroyed with certainty 
by these means. 

Drs. Reik and Watson, of Baltimore, have con- 
cluded from their experiments that metallic instru- 
ments may be rendered sterile by immersion in a 
solution of a strength of 1 to 2000 for thirty-five 
minutes. As the solution is neither corrosive to in- 
struments nor irritating to the skin when used in any 
strength, it would seem better to use the stronger 
solutions, from 10 per cent, to 40 per cent., and thus 
shorten the period required for the disinfection. 

For the disinfection of instruments in general, 
boiling water leaves nothing to be desired, but the 
formalin disinfection may be used to advantage for 
the sterilization of those articles which are injured 
by boiling, as cutting instruments, catheters, etc. It 
is especially urged that it should supersede alcohol 
for this purpose. 



MEANS OF STERILIZATION. 47 

Lysol is one of the coal tar products, and con- 
tains about 50 per cent, of the cresols. It is miscible 
with water, forming a clear, saponaceous mixture. 
It may be used in 1- to 2-per-cent. solution. Ac- 
cording to Coblentz, a 1-per-cent. solution of lysol 
is equal in antiseptic power to a 5-per-cent. solution 
of carbolic acid. According to experiments made at 
the Boston City Hospital, it requires from 20 to 30 
minutes for pure lysol to destroy germs. It there- 
fore should not be classed as a germicide to be used 
in any aseptic preparation, unless as a mild antisep- 
tic upon mucous surfaces that would be injured by 
the corrosive disinfectants. For this purpose it is 
preferable to carbolic acid. 

Iodoform is extensively used on wound surfaces 
and is generally regarded as a germicide. It is pos- 
sible for germs to live in contact with it, but they 
cannot multiply. It should not be used unless upon 
suppurating wounds. If freely used it may cause 
serious symptoms of poisoning. These symptoms 
are characterized by rapid pulse and active delirium. 

Iodoform appears to have a distinctive ac- 
tion upon the bacilli of tuberculosis in the tissues. 
Whether this is because the bacilli are especially 
susceptible to the iodoform or whether active tissue 
changes, which destroy the germs, are caused by 
the drug, it is impossible to say. 

Aristol is superior to iodoform as a disinfectant 
except where the tubercle bacilli are the infecting 
agents. It is non-toxic, is free from objectionable 
odor, and has no tendency to grow lumpy. 

Peroxide of Hydrogen has considerable germicidal 
power, from the oxygen liberated when it comes in 



48 SURGICAL ASEPSIS. 

contact with pus. Its value is enhanced by its me- 
chanical action from the liberation of gas, thus 
throwing the pus out from hidden pockets and deep 
sinuses. It is especially efficient in freeing the hands 
from putrefactive odors after septic cases. 

Honsell states that a 3-per-cent. solution is 
equal in germicidal power to a 1 to 1000 solution 
of bichloride of mercury. 



CHAPTER V. 

PRACTICAL APPLICATION OF THE PRINCIPLES 
OF STERILIZATION. 



No SET rules can be laid down for the prepa- 
rations for an aseptic operation. Every individual 
surgeon will work out a way in which he can best 
accomplish the end, and he will often find it con- 
venient to change his usual routine, according to the 
time at his disposal and the material to be obtained. 
This may be done with safety if he will but keep 
constantly in mind the general principles of steril- 
ization. 

Skin Disinfection. — Everything connected with 
any surgical operation may be rendered absolutely 
free from living germs except the hands of the op- 
erator and his assistants and the field of operation. 
The skin furnishes all the requisites for the lodg- 
ment and propagation of germs. It has an equable 
temperature, the secretion of the cutaneous glands 
provides the necessary moisture, and the animal and 
vegetable substances furnish an excellent culture 
medium. As might be expected, the surface of the 
body swarms with bacteria of the most varied spe- 
cies. Especially is this true in respect to the hands 
of the surgeon, as they are repeatedly in contact 
with diseased tissues and infected wounds. 

The surface of the skin may be freed from 
germs, but the deeper layers always harbor some 

(49) 



50 



SURGICAL ASEPSIS. 



organisms, and these gradually find their way to the 
surface during the operation. In the application of 
the principles of disinfection to the skin, the me- 
chanical cleansing is of the utmost importance. The 
inefficiency of the chemical antiseptics has shown 
the necessity of the thorough removal of the bac- 




teria from the surface of the skin by scrubbing and 
washing. 

This mechanical cleansing of the skin is the 
preliminary to all methods of skin disinfection and 
should be very thorough and painstaking. The nails 
should be short and freed as much as possible from 
dirt by means of the nail cleaner. The hands and 




Fig. 14. — Cheap Nail Brush. 



forearms should then be washed for several minutes 
with soap and water as hot as can be comfortably 
borne. During this process the water should be 
changed several times, and the nail brush should be 
used on the hands and especially about the knuckles 
and nails. 

No definite rule can be laid down for the length 



PRACTICAL APPLICATION OF PRINCIPLES. 51 

of time this scrubbing should continue, as its effi- 
ciency will depend much upon the dexterity of the 
individual and the condition of his skin. A thick, 
rough or cracked skin furnishes hiding places for 
germs, from which they are dislodged with consid- 
erable difficulty. 

The minimum time for which this scrubbing 
should continue may be placed at five minutes, and 
Robb found that cultures taken from the hands after 
scrubbing for ten minutes always showed less bac- 
teria than those taken after only five minutes' work 
had been done. 

The soap to be used for the scrubbing should 
be strongly alkaline and should also contain alcohol 
or ether. The free alkali softens the epidermis and 
loosens the epithelial scales, while the alcohol or 
ether dissolves the fat from the skin and allows the 
after-coming chemical disinfectants to extend more 
deeply. 

The tincture of green soap and Johnston's ethe- 
real antiseptic soap answer these requirements. Of 
late several brands of soap have been offered in 
which some germicide is incorporated. Of these, 
the most reliable are McClintock's germicidal soap 
and synol. 

The germicidal soap carries a definite quantity 
of biniodide of mercury, and a 1-per-cent. solution 
of the soap makes a 1 to 5000 solution of the mer- 
curic iodide. This has been proven to be an efficient 
germicide. 

Synol contains a fixed, but unpublished, amount 
of the cresol bases as its germicidal agent, and the 
cresols, of which lysol is the best exponent, have 



52 SURGICAL ASEPSIS. 

been shown to be slow in germicidal action. Yet 
Dr. Goelet, from an extended use and from labora- 
tory experiments by scrapings from the skin, is satis- 
fied that this is a reliable germicide and employs no 
other method of skin disinfection. 

Both these preparations, even if their germ.i- 
cidal properties are proven, have the disadvantage 
of being unknown to us as to the exact strength of 
the solution. 

Until further use and experiment have proven 
their reliability, chemical disinfection should follow 
the cleansing by soap and water, and should not be 
combined with it. 

Various methods of skin disinfection are re- 
garded as efficient. Probably the most generally 
used is that originated by Fiirbringer. The surface 
is thoroughly scrubbed with green soap and water, 
then for one minute with alcohol, and finally soaked 
for five minutes in 1 to 2000 bichloride. As it has 
been shown that alcohol is in no sense a germicide 
and that solution of bichloride of mercury in the 
strength of 1 to 1000 is not certainly destructive to 
bacteria even in fifteen minutes, it will be seen that 
this method is defective. 

A method of skin disinfection now used by 
many surgeons is by the combined use of chloride 
of lime and carbonate of soda. The chemical union 
of these salts results in free chlorine gas, which is 
a reliable germicide. After the preliminary scrub- 
bing with soap and water, about a tablespoonful 
each of chloride of lime and of carbonate of soda 
are placed in the palms of the hands, and enough 
water is added to make a smooth paste. The paste 



PRACTICAL APPLICATION OF PRINCIPLES. 53 

should be thoroughly rubbed into the skin of the 
hands and forearms and about the nails for at least 
five minutes and should then be washed away with 
hot, sterile water. 

The objectionable odor which this leaves upon 
the hands for several hours may be removed by 
washing them in water containing about 10 per cent, 
of aqua ammonia, the chlorine uniting with the am- 
monia to form ammonium chloride. 

The method elaborated at the Johns Hopkins 
Hospital and brought into quite general use through 
the efforts of Robb, is much more painstaking, and 
is correspondingly more effective in the destruction 
of ■ pathogenic bacteria. Whenever the peritoneum, 
the joints, the brain, or the medullary canal of the 
long bones is to be invaded, this method should be 
used. 

The successive steps in this method of disinfec- 
tion are : — 

1. Scrubbing and washing with soap and water. 

2. Application of solution of potassium perman- 
ganate. 

3. AppHcation of solution of oxalic acid. 

4. Immersion in solution of bichloride of mer- 
cury. 

After the mechanical cleansing, the excess of 
soap should finally be rinsed off with hot, sterile 
water, and a warm, saturated solution of potassium 
permanganate should be well rubbed into the skin. 
This should continue for two or three minutes. By 
this time the skin will have become stained a deep 
mahogany brown. It is decolorized by an 8- or 10- 
per-cent. solution of oxalic acid. The hands should 



54 SURGICAL ASEPSIS. 

then be immersed in a solution of bichloride of mer- 
cury in strength of 1 to 1000 or 1 to 2000 for five 
to ten minutes, using the nail brush over the sur- 
face and especially about the nails. The simple 
immersion of the hands in bichloride solution for 
a few seconds or even a minute or two is insuffi- 
cient for the destruction of germs. By the most 
painstaking methods even we can seldom absolutely 
free the skin from germs, but it can usually be ren- 
dered so nearly sterile that the tissues are able to 
resist the action of the small number of remaining 
bacteria. 



Fig. 15. — Rubber Operating Glove. 

Rubber operating gloves have recently come 
much into favor. By their use, the aseptic technique 
can be rendered perfect excepting as regards the 
field of operation. The use of gloves somewhat in- 
terferes with the sense of touch, which is so impor- 
tant, especially in abdominal work. They are very 
useful in making any preparation of the patient after 
the hands are steriHzed. The gloves will protect the 
hands from any infection and they may be turned 
off, just before beginning the operation and the 
hands immersed in bichloride solution. The objec- 
tion which the surgeon may have to the use of gloves 



I 



PRACTICAL APPLICATION OF PRINCIPLES. 55 

during the operation does not apply to his assistants. 
It will lessen the danger of infection if the assistants, 
who touch the wound or sponges, wear the gloves. 
They may be sterilized by washing in soap and water 
and then immersed in bichloride-of-mercury solution 
of a strength of 1 to 1000 for not less than half an 
hour. 

A still better method is by boiling. The gloves 
will stand boihng for several times, but are injured 
to some extent by it. 

It is difhcult to put the gloves on without tear- 
ing them. Some use sterilized French chalk. If this 
is used it is best done by putting a small quantity 
into each glove and then tying a piece of tape or 
wrapping twine tightly about the wrists of the gloves 
before putting them in the solution to boil. A better 
method is to place them in a 1-per-cent. lysol solu- 
tion after boiling. The lysol solution is mildly anti- 
septic and acts as a lubricant, so that the gloves may 
be drawn on easily. 

Lisle thread gloves have been recommended 
and used to some extent. They may be sterilized 
by steam, but, as they soon become soaked during 
the operation, they take up the bacteria which come 
to the surface of the skin. It has been found by 
experiment that the number of bacteria contained 
in them steadily increases according to the length 
of time they are worn. 

For the disinfection of the field of operation 
when it is on the external surface of the body, the 
same method should be used as for the sterilization 
of the hands of the surgeon, in addition to the pre- 
liminary preparation, which will be described in a 



56 SURGICAL ASEPSIS. 

subsequent chapter. Even approximate sterilization 
of mucous surfaces is very difficult. In addition to 
the preliminary preparation given by the nurse, the 
vagina should receive the especial attention of the 
surgeon when the operation is to be made by this 
route. This will be more fully described under the 
chapter dealing with vaginal operations. 

Disinfection of the Operating Room. — Infection of 
a wound must come either from contact or from 
dust floating in the room. There can be Httle dan- 
ger from room infection so long as there is no dust 
floating. Any room in which a major operation is 
to be performed should be thoroughly stripped of 
carpets, pictures, and superfluous furniture which 
may harbor dust. This should be done at least 
twenty-four hours previous to the operation, that 
all dust may have time to settle. 

After a few hours all the wood-work should be 
washed with soap and water. This is all that is nec- 
essary, but the wood-work may be washed with a 
solution of mercuric chloride if desired. If there 
has been a case of infectious disease — as diphthe- 
ria, erysipelas, or tuberculosis — in the house, this 
should not be omitted, and in addition the gaseous 
disinfection by means of formaldehyde gas should 
be used. 

This may be carried out by vaporizing 16 ounces 
of formalin to each 1000 cubic feet of space. In- 
stead of formalin, wood alcohol may be used in the 
proportion of 30 ounces to each 1000 feet. For- 
malin may now be purchased so cheaply that it is 
preferable. The room should be tightly closed for 
twelve hours. 




o 



r3 
C 

B 

o 
o 

I 



.-^^^ te^» A^^ %m. 



PRACTICAL APPLICATION OF PRINCIPLES. 57 

When an emergency operation must be done 
immediately, it is better not to remove anything 
from the room, on account of filHng the air with 
dust and its accompanying bacteria. If there is no 
carpet on the floor it should be wiped over with a 
cloth wet with a solution of bichloride of mercury. 
Should there be a carpet, it should on no account 
be swept, but should be covered with sheets which 
have been moistened in bichloride solution. 

Operating and Instrument Tables, etc. — All these 
may be disinfected by soap and water, followed by 
mercuric chloride solution. In order that the bi- 
chloride solution may be effective, towels or cloths 
should be wrung out of the solution, laid on the 
surface to be disinfected, and may be allowed to 
remain there until ready for use. Glass top tables 
are well sterilized by this method. Tables with 
wooden tops are not completely sterilized, but should 
be covered by sterile towels or sheets before being 
used for dressings or instruments. 

Basins, Pitchers^ and Instrunient Trays. — These 
may be steriHzed by thorough mechanical cleansing 
and then a prolonged washing with bichloride solu- 
tion 1 to 1000. It is better to scald each one by 
pouring boiling water into it and then fill with solu- 
tion of bichloride of mercury and allow it to stand 
for fifteen minutes. 

Operating Pad and Irrigating Bag. — These may 
also be sterilized by soap and water and bichloride 
solution. 

The operating pad is one of the most conven- 
ient articles in the surgeon's armamentarium, but 
we would lose nothing in the way of a rigid tech- 



58 



SURGICAL ASEPSIS. 



nique if its place were supplanted by a rubber cloth 
covered by a sterile sheet. The operating pad should 
be covered by sterile towels after the disinfection of 
the patient has been completed. 

The irrigating bag or fountain syringe will 
withstand boiling, and, unless it is new, this method 
should be used. 




Fig. 18. — Kelly's Laparotomy Pad. 

Instniments. — There are various methods for the 
sterilization of instruments, but, as the simplest is 
the most efficient, that alone will be described. For 
all instruments in which it is possible only those 
which are entirely of metal should be purchased. 
For knives and some other instruments the plain 



J 



PRACTICAL APPLICATION OF PRINCIPLES. 59 

metal handles are slippery when wet and in small 
knives are somewhat heavy to balance the blade. 

Scalpels and amputating knives with vulcanized 
rubber handles baked on to the steel furnish no 
lodging place for germs. They possess all the ad- 
vantages of the wood or ivory handles and can be 
as readily rendered aseptic as those made entirely 
of metal. Aluminum is attacked by sodium carbo- 
nate. Heat, by the means of boiling water, is the 
simplest way of sterilizing instruments or any other 
article which is not injured by its action. 

Sodium Carbonate, in a 1-per-cent. solution or 
a teaspoonful to a quart, prevents the rusting of 
instruments and shortens the time necessary for the 
sterilization by its solvent action on all organic ma- 
terial. 

Many instrument sterilizers are made, but they 
are entirely unnecessary. Any tin pan or basin large 
enough to receive the instruments is all that is re- 
quired. The pan itself is sterilized at the same time 
as the instruments, and may be used as an instru- 
ment tray in the absence of a tray or sterile towels 
upon which they may be placed. In a private op- 
erating room it is convenient to have a tin or copper 
pan with a wire basket which may be placed inside 
so that the instruments may be lifted out of the 
water. Instead of this, the instruments may be 
placed in a cloth bag, fastened at the top by a tape 
which is long enough to allow the ends to hang over 
the side of the sterilizing pan or kettle. The instru- 
ments may be lifted from the pan by means of this 
tape, the water poured from the pan, and the instru- 
ments may be replaced in it until ready to be ar- 
ranged on the tables. 



60 SURGICAL ASEPSIS. 

The instruments will be sterilized by boiling 
water in five minutes, but they may be left longer 
without harm. The temper of cutting instruments 
is injured by repeated steriUzation by heat. If knives 
are boiled with other instruments the blades should 
be wrapped in cotton to avoid dulling. 

Instead of sterilization by heat, cutting instru- 
ments may be immersed in a 5-per-cent. solution of 




j'ig, i9._Kean's Instrument Sterilizer. 

carboHc acid for three hours or a 20- to 40-per-cent. 
formalin solution for half an hour. The formalm 
disinfection is preferable. 111- 

Disinfection by means of absolute alcohol is 
inefficient. It inhibits the multiplication of germs, 
but is not destructive to them. 

Operating suits, sheets, towels, dressings, gauze 
drains, gauze sponges, silk ligatures, and silk-worm 



PRACTICAL APPLICATION OF PRINCIPLES. 61 

gut sutures may all be sterilized in the steam steril- 
izer. They should be made into packages of con- 
venient size and wrapped in clean cotton sheeting. 
This should not contain much sizing and should be 
thick enough to prevent any contamination through 
its meshes after the packages are sterilized. Each 
package should be marked with pencil, so that the 
required articles may be readily found without open- 
ing all the packages. 

When pathogenic bacteria are freely exposed 
to the action of steam at 212° F., all excepting the 
spore-producing forms are destroyed in fifteen or 
twenty minutes. But in packages the interior is not 
so freely exposed to live steam, and the sterilization 
should be continued for forty-five to sixty minutes. 

Silk which is to be used for buried ligatures or 
sutures and gauze to be left in the wound for pack- 
ing or drainage should be sterilized, when possible, 
by the fractional method. The sterilization of these 
articles would better be done at the place of opera- 
tion. If for any reason it is impossible to carry a 
sterilizer, they may be doubly wrapped in cotton 
cloth, sterilized at home, and carried in the surgeon's 
bag. The sterilizer takes very little additional room, 
as it may be packed full of the dressings, etc. 

Rubber and Glass Drains may be sterilized in 
boiling water or in bichloride solution. Silver wire, 
when used for sutures, may be sterilized by boiling 
water with the instruments. Silk-worm gut may 
also be sterilized by boiling water. It is colored and 
somewhat softened by the soda solution and should 
be boiled in plain water. 

The most reliable animal ligatures are pur- 



62 SURGICAL ASEPSIS. 

chased already sterilized in sealed glass tubes. The 
outside of these tubes may be sterilized by placing 
them in bichloride of mercury solution for a few 
moments. 

Water for Sponging. — Dry sponging may be 
employed, or the sponges may be washed in sterile 
water and squeezed as dry as possible. Water is 
readily sterilized by boiling it for five or ten min- 
utes. To have sterile water of the proper tempera- 
ture it is necessary to have a supply which has been 
previously sterilized and allowed to cool, and also 
a supply of hot, sterile water. The simplest method 
of obtaining this in private work is to have at least 
four nickeled tea-kettles. Two of these may be filled 
with water and sterihzed several hours before the 
operation. They are then set away to cool. The 
remainder are for the hot, sterile • water. When 
ready for the operation all these kettles are carried 
to the operating room, and the water is used directly 
from them. The water should be strained through 
several thicknesses of gauze or absorbent cotton be- 
fore sterilizing. This may be accomplished by tying 
gauze over the faucet. If this has been neglected, 
sterile gauze may be tied about the spout of the 
kettle, and the water is strained as it is poured from 
it. There is more danger of contamination in this 
way. If the nickeled kettles cannot be obtained, the 
water may be sterilized and poured into sterilized 
pitchers.. A sterile towel or cloth should be tied 
over the pitcher until the water is needed. 

Normal Salt Solution. — This may be needed for 
flushing out the abdomen in cases of purulent in- 
fection, as a rectal enema, for injection into the 



PRACTICAL APPLICATION OF PRINCIPLES. 63 

cellular tissue or directly into the veins in case of 
shock. 

It must be prepared so that 1 or 2 gallons may 
be available at any moment and of the proper tem- 
perature. It is made of the same specific gravity as 
the blood, and the proper proportion is ^/lo of 1 
per cent, or about 45 grains (3 grammes) to the 
pint. 

Several powders should be weighed out by the 
druggist, each of which is sufficient for 1 gallon of 
water. In the absence of these, an even table- 
spoonful to the gallon is about the right proportion. 
When the solution is needed, one of these powders 
should be dissolved in a few ounces of water and 
sterilized by boiling. This concentrated solution is 
then set aside until the solution is required. It is 
then added to 1 gallon of sterile water from the ket- 
tles, mixed in such proportion as to give the desired 
temperature. The concentrated solution is of so 
small amount that its addition to 1 gallon of water 
makes very slight difference, either in the tempera- 
ture or percentage of the salt. When the solution 
is used in the abdomen it should range from 100° 
to 110° F. The temperature is often tested by the 
hand of the nurse, but this is an unreliable guide 
and it increases the danger of infection. The hands 
of the nurse, especially if she has been wringing 
sponges or had them in hot solution, may be so 
accustomed to heat that the temperature of the fluid 
may be 120° to 125° F. This temperature will al- 
ways inflict injury on the peritoneum, and increases 
the danger of adhesions and infection. The heat 
should be tested by thermometer when possible. 



64 SURGICAL ASEPSIS. 

The thermometer should be a plain glass one of the 
same style as a clinical thermometer. It is necessary 
that it should be graduated up to 212^^ F. to avoid 
bursting if placed in very hot liquids. 



CHAPTER VI. 

ACCESSORIES NECESSARY FOR OPERATION. 



In hospital practice or when the surgeon can 
avail himself of the advantages of his own private 
operating room, the details of an aseptic operation 
may be much more easily carried out than in the 
home of the patient. There are, however, no insur- 




Fig. 20.— Edebohls-Morris Operating Table. 

mountable obstacles to perfectly aseptic work, even 
in the humblest dwelling. This chapter will be de- 
voted to a consideration of the accessories desirable 
in the private operating room, and to the substitutes 
which may be used when necessary. 

Operating Tables. — The glass top operating tables 
for operating rooms are not only convenient on ac- 
count of their perfect mechanism, but for the ease 
with which they may be cleansed. 

(65) 



66 



SURGICAL ASEPSIS. 



The table devised by Dr. Edebohls and modi- 
fied by Dr. Alorris is a good type for the operating 
room, but is not easily portable. 

The Buchanan table is easily portable, as it 
may be folded into a small compass, and all the 
positions may be easily secured. It is to be recom- 
mended for the small operating room or for the sur- 




Fig. 21. — Buchanan's Operating Table. 



geon who often operates in the home of the patient; 
but a table of this type recommends itself more from 
its convenience than from necessity. 

An ordinary kitchen table, lengthened, if need 
be, by a stand, may be used in private houses. If a 
stand is needed to lengthen the table it would better 
be placed at the head, and any variation in height 
may be remedied by the use of pillows. Instead of 



ACCESSORIES NECESSARY FOR OPERATION. 67 

using a stand the table may be lengthened by placing 
on its top a board of the required length and width. 
An improvised operating table of this sort is 
prepared by the usual disinfection, covered with a 
clean folded blanket, and this in turn by a sterile 
sheet. A table arranged in this manner compen- 
sates, to some extent, for its disadvantages in secur- 
ing positions by the conservation of the body-heat 
of the patient, which cannot be well done with the 
uncovered glass table. 




Fig. 22. — Krug's Trendelenburg Frame. 

If the Trendelenburg position is necessary it 
may be secured by the use of Krug's frame. 

By means of this device any flat top table may 
be quickly converted into one which permits the 
elevation of the pelvis to any desired degree. It 
may be folded into a small compass for transporta- 
tion, and is easily clamped to any table. 

If this appliance is not at hand, the Trendelen- 
burg position may be secured by raising the hips of 
the patient and placing a kitchen chair on the table. 



68 



SURGICAL ASEPSIS. 



The chair should be so placed that its back forms 
an inclined plane. The top of the chair is under the 
patient's shoulders, and his legs, bent at right angles 
at the knee, hang over the rounds of the chair. The 
rounds of the chair should be covered by a pillow, 
or a sheet or blanket may be tightly pinned about 
the four legs of the chair in such a manner that it 
covers well the bottoms of the chair legs. By the 




Fig. 23. — Edebohls's Lithotomy Crutch. 

use of a chair in this manner a Trendelenburg posi- 
tion of from forty to forty-five degrees is obtained. 

The dorsal position for operations by the vagina 
or rectum may be secured in a variety of ways. Ede- 
bohls's leg holders may be had, and may be at- 
tached to any table. Robb's canvas operating strap 
is a convenient leg holder and takes very little room 
in the operating bag. 

The operating strap is made of heavy Canton 



ACCESSORIES NECESSARY FOR OPERATION. 69 

flannel of double thickness and closely quilted. It 
is about six feet in length and three inches wide in 
the center, gradually tapering toward the ends. It 
is made adjustable to any patient by means of snaps 
at each end and by metal rings attached to the strap 
by strong tape. The strap is passed over the neck 
of the patient and the ends fastened around each 
thigh just above the knee by means of the snaps and 
rings. 

If neither of these appHances is at hand, the 




Fig. 24. — Position for Vaginal Operations. 

Robb leg holder may be replaced by a sheet, folded 
diagonally like a cravat. It is placed over the neck 
and the ends tied around each thigh. 

Tables for Instruments and Dressings. — An abun- 
dance of table room renders the maintenance of the 
technique much less difficult than when a variety of 
articles must be placed together and frequently 
handled. The same remarks apply to instrument 
tables as were made of operating tables. The glass 
top tables may be sterilized so that instruments may 



70 



SURGICAL ASEPSIS. 



be placed directly on the table. If the wooden tables 
are used, they should be well covered with sterile 
towels before the instruments are placed on them. 
The towels should completely co^ er the top of the 
table and overhang the edges. In private houses, if 
ordinary small tables or stands are used, six are none. 
too many, although two will do if unable to obtain 




Fig. 25.— Glass Top Instrument Table. 



more. Wooden chairs which have been covered by 
clean sheets may be used instead of tables, for basins 
containing the sponges or the solutions for the 
hands. 

Basins, Pitchers, and Operating Trays. — Not less 
than six wash-bowls or basins should be provided, 
and an equal number of pitchers may be needed for 
solutions. If nickeled kettles are used for the sterile 



ACCESSORIES NECESSARY FOR OPERATION. 71 

water," four pitchers will be sufficient. Usually this 
number of basins and pitchers may be found at any 
house or readily procured in the vicinity. The sur- 
geon can easily carry several basins of granite iron- 
ware or agateware. If they are of uniform size and 
shape they occupy very little room when nested. 

Usually, when an abundance of sterile towels 
may be had, the most convenient method of arrang- 
ing the instruments is on the table covered with 
sterile towels. Instead of this the instruments may 



Fig. 26. — Agate Instrument Tray. 

be placed in an instrument tray furnished by the sur- 
geon or on a large platter found in the house. A 
separate plate for Hgatures and sutures avoids an- 
noyance. 

Several nickeled kettles are a convenience. The 
water may be sterilized in these and used directly 
from them instead of using from pitchers. Every 
transfer of this nature, especially with untrained as- 
sistants, adds to the uncertainty of the result. An 
ordinary tin pan may be used for sterilizing the in- 
struments, or the instrument tray or one of the 



T2 



SURGICAL ASEPSIS. 



agateware basins carried by the surgeon may be used 
for this purpose. 

Irrigating Apparatus. — Almost any wound may 
require irrigation, and some apparatus should al- 




Fig. 27. — Glass Irrigator. 

ways be available. For the private operating room 
a glass or porcelain irrigator that will hold three or 
four quarts is best. The best form is a graduated 
pitcher with an outlet near the bottom to which a 




Fig. 28. — Glass Irrigating Pipe. 



piece of rubber tubing may be attached. This rubber 
hose may be slipped off and sterilized by boiling be- 
fore each operation. 

A variety of irrigating nozzles may be had. The 



ACCESSORIES NECESSARY FOR OPERATION. 



73 



best for general use is a plain glass one with a large 
Opening. The glass portion of a medicine dropper 
may be used. If the opening is too small the end 
may be broken off. 

The more portable irrigating appliances are 
Lee's siphon syringe and the fountain syringe. The 
Lee siphon is like an ordinary bulb syringe, but is 
provided at its distal end by a U-shaped clip, by 
means of which it may be attached to the rim of a 
pitcher or pail. In the absence of any irrigating 




Fig. 29. — Lee's Siphon Irrigator. 



apparatus, the liquid may be poured into the wound 
from a pitcher. 

Operating Suits. — The surgeon and his imme- 
diate assistants should wear operating suits which 
completely cover the street clothing. It is better to 
have clean gowns for all invited guests, but it is not 
indispensable unless they come in contact with the 
assistants, the operating table, or other aseptic para- 
phernalia. 

The suits may be either made with coat and 
pants or simply a gown. The gown is most conven- 



u 



SURGICAL asepsis: 



ient, and if made large about the neck, and tied with 
tape at the waist, it may be made to fit any person. 
It should reach below the knees, and the sleeves only 
to the elbows. Heavy drilling or white duck is the 
best material for these suits. If the suits are not at 
hand, white duck coats — which may be found at al- 
most any clothing store — may be used, or a sterile 
sheet may be folded so that it will give the proper 




Fig. 30. — Fountain Syringe Arranged as an Irrigator. 



length, pinned at the shoulders and tied about the 
waist with tape. 

Sheets and Towels. — At least three sheets should 
be provided. For an abdominal operation a lapa- 
rotomy sheet with a circular opening in the center 
may be used to advantage. Instead of this a gauze 
diaphragm may be used. A piece of sterile gauze 
two or three feet square may be used to cover the 
abdomen and a circular or oval piece cut out over 
the site of the incision. An abundance of towels 



ACCESSORIES NECESSARY FOR OPERATION. <5 

should be provided. Usually two dozen are needed. 
They should be sterilized in packages of one-half 
dozen each. 

Two or three nail brushes should be at hand. 
They should either be new or should be soaked for 
an hour or more in bichloride solution. It is better 
to purchase cheap brushes, which can be thrown 
away and new ones used for every major operation. 




Fig. 31. — Surgeon's Operating Gown. 

Two slop buckets are necessary, one to be 
placed so that the fluids from the operating table 
may drain into it, and the other to be used for the 
reception of the discarded sponges and fluids. 

A plate or other receptacle should be in readi- 
ness for the reception of any diseased tissues to be 
removed. 



CHAPTER VII. 

GAUZE, SPONGES, LIGATURES, AND SUTURES. 



Absorbent gauze may be purchased in pack- 
ages of five, twenty-five, or one hundred yards. It 
is used for dressings, bandages, compresses, gauze 
sponges, and gauze and cotton mops. In abdominal 
operations it is useful for walling off the field of 
operation from the other portions of the peritoneal 
cavity. A long strip may be used for dry sponging 
instead of gauze sponges. For these purposes, sev- 
eral pieces of gauze one yard or more in length, and 
hemmed at each end, are useful. 

Absorbent Cotton is used as a dressing and also 
sometimes in the composition of sponge substitutes. 
When sterilized for a dressing it should be cut of 
the proper size before sterilizing. It cannot be 
effectually sterilized in the roll unless exposed to the 
action of steam for a long time. 

Sponges and Sponge Substitutes. — The use of ma- 
rine sponges in all major operations has been almost 
entirely discarded. They cannot be sterilized by heat 
on account of the shrinking and hardening which it 
causes. 

Chemical disinfection is inefficient. If they are 
to be used it is better to purchase the so-called 
"aseptic" sponges, which are sold by all dealers in 
surgeons' supplies. These are not sterile, but they 
have been properly cleansed of sand and other ex- 
(76) 



GAUZE, SPONGES, LIGATURES, SUTURES. 77 

traneous matter. To render them reasonably sterile 
they may be soaked for an hour in a 1-per-cent. solu- 
tion of potassium permanganate, decolorized in a 
2-per-cent. solution of oxalic acid, rinsed in sterile 
water, and preserved in a 1 to 1000 bichloride solu- 
tion or a 3-per-cent. solution of carbolic acid. Ma- 
rine sponges may always be replaced to advantage 
by one of the substitutes. 

Gauze Sponges are made from absorbent gauze, 
folded in several thicknesses and the edges either 
hemmed or so folded that the cut edges are all 
turned in, and the sponge retains its shape without 
stitching. 

Several sizes are convenient, and for this pur- 
pose the gauze should be folded double and cut in 
rectangular pieces from nine to twelve inches square. 
If the sponges are to be sewed, these pieces of gauze 
may be folded in any manner that makes the sponge 
of the desired size. 

If the sponges are to be folded and not stitched, 
considerable care is necessary to fold all the rough 
edges inside. A convenient way is to cut a strip of 
gauze about eighteen inches wide and of any desir- 
able length. This is folded lengthwise in the middle 
to make a double thickness. It is then folded in 
thirds, the free edges being folded in first. We now 
have a long strip of gauze about 2 ^ / ^^ to 3 inches 
wide. This strip is now cut into pieces about 6 or 
8 inches long. This is folded crosswise in thirds, 
making a pledget of gauze about 3 by 3 ^/a inches 
in size. Now pick up one thickness of gauze, and, 
holding the remaining portion firmly, turn the 
pledget inside out. This leaves ragged edges at one 



78 



SURGICAL ASEPSIS. 



end; so, picking up the double thickness of gauze 
at the other end of the pledget, it is again turned 
inside out, thus covering up the cut edges, and the 
sponge is completed. Large flat compresses, made 
like the sponges, but five or six inches square, are 
sometimes useful for protecting the intestines. 

Gauze and Cotton Mops are made by wrapping 
absorbent cotton in squares of gauze. The corners 
are brought together and tied with thread and then 
cut off close to the thread. These may be bought 




Fig. 32. — Gauze and Cotton Sponge Substitute. 



in any size from one-half inch to three inches in 
diameter for a little more than the cost of the mate- 
rials. 

Iodoform Gauze. — It has been sufhciently em- 
phasized that no antiseptics are necessary or should 
have any place in an aseptic operation. This is al- 
w^ays true when only tissues which are free from 
germs are implicated in the operation. In such 
cases plain sterile gauze is much to be preferred, 
either for drainage or for packing of the wound. 
When a pus-cavity must be drained, or the wound 



GAUZE, SPONGES, LIGATURES, SUTURES. 79 

is in tissues which cannot be freed from bacteria and 
kept sterile, iodoform gauze may be of use. Iodo- 
form does not destroy bacteria, but it inhibits their 
growth. When iodoform gauze is used it should 
be steriHzed in the same manner as the plain gauze. 

Gutta-percha Tissue is useful as a protective over 
wounds and also in making the wick drainage after 
the method of Dr. Robert T. Morris. 

It may be sterilized by soaking in 1 to 1000 
solution of bichloride of mercury for not less than 
one-half hour. The solution in which it is soaked 
must be cold, as hot solution ruins the tissue. 

White Cotton Wadding, such as is used by tailors, 
makes a very smooth dressing when applied over 
absorbent gauze. It is not absorbent, and should 
not be used when drainage is employed. 

Ligatures and Sutures. — Silk and catgut are used 
for ligatures; and silk, catgut, kangaroo tendon, 
silk-worm gut, and silver wire are used for sutures. 

Aseptic sutures or ligatures of non-absorbable 
material are usually encapsulated in the tissues and 
cause no irritation, but they may give rise to sup- 
puration and be the exciting cause of a chronic sinus 
which will persist until the offending substance is 
discharged or removed. The difficulty in securing 
aseptic absorbable ligatures and sutures, and the 
danger of too rapid absorption, has in the past led 
many surgeons to rely almost entirely upon those 
which are non-absorbable. . By the improved meth- 
ods of sterilizing and preserving catgut both these 
objections are overcome, and very little is left to be 
desired for buried sutures and ligatures. For skin 
sutures and certain operations in which a permanent 



80 SURGICAL ASEPSIS. 

suture is desired some other material may be prefer- 
able. 

Silk is very freely used by many surgeons. It 
can be certainly sterilized by steam or by boiling 
when needed in an emergency. It has the advan- 
tage of tying securely and with a small knot. From 
its strength it may be used of a small size and in a 
needle which will not cut the tissues. For this 
reason it cannot be well replaced in intestinal work. 
In most other work it may advantageously be re- 
placed by some other material. The most conven- 
ient way to sterilize and preserve silk sutures is to 
wind various sizes on small glass spools. These are 






Fig. 33. — Test-tube with Glass Spools for Sterilizing Silk. 

placed in a large ignition test-tube, plugging with 
non-absorbent cotton. They are sterihzed in the 
steam sterilizer, preferably by the fractional method. 

Silk-zi'orm Gut is almost an ideal non-absorbable 
suture. It is very strong and is easily sterilized. 
There are no open meshes, and it offers no lodging 
places for bacteria, should the wound become in- 
fected. It comes in three sizes. The medium size 
is generally sufficient for all purposes. 

If it is sterilized by steam, a sufficient number 
of strands should be selected and the curled ends 
cut off. The bundle of strands may then be doubled 
once and placed in a test-tube, or may be rolled in 



GAUZE, SPONGES, LIGATURES, SUTURES. 81 

a coil and wrapped in muslin to be sterilized with 
the dressings. It may be very quickly sterilized by 
boiling for five minutes, just previous to the opera- 
tion; it should be boiled by itself, and not with the 
instruments, as the soda solution colors and softens 
it. 

Silver Wire, which was an old-time favorite, has 
nearly gone out of use as a suture on account of the 
difificulty in its introduction and removal. 

Recent experiments have shown that metallic 




Fig. 34.— Coil of Silk-worm Gut. 

silver has an antiseptic property of its own, and for 
a permanent buried suture this should give it a 
claim. For external sutures and for the closure of 
fistulse silk-zvorm gut possesses nearly all the advan- 
tages of silver wire and is much more flexible. 

Silver wire would be an ideal permanent buried 
suture were it not for the pain and irritation which 
may be caused by its twisted ends. It is especially 
adapted to uniting bony surfaces. The ends after 
being twisted are hammered down flat against the 
surface of the bone, or a slight excavation may be 



82 SURGICAL ASEPSIS. 

made with a gouge for the reception of the knot. 
Some operators also use silver wire as a buried su- 
ture in operations for hernia and for closing ordinary 
abdominal incisions. It may be steriHzed in the soda 
solution with the instruments. 

Catgut is the most useful material we possess for 
sutures and ligatures, and it is also the most difficult 
to sterilize, since, being made from the intestine of 
the sheep, it furnishes an excellent soil for all kinds 
of bacteria. Until recently there has been no method 
known by which the microbes could be with cer- 
tainty destroyed without destroying also the strength 
of the material. The manipulation necessary is so 
lengthy and requires such extreme care and special 
apparatus that only one who is a master of aseptic 
technique and has had experience in this work can 
successfully prepare it. As this is intended as a 
guide for the general practitioner, no minute de- 
scription of the preparation will be made. 

Until recently it was impossible to obtain a re- 
liable article from dealers, as the workmen were 
ignorant of the necessity for absolute asepsis, even 
if they had been taught the technique. Moreover, 
if a quantity of aseptic catgut was secured, it was 
almost impossible to preserve it in that state for 
repeated operations, as it was apt to become con- 
taminated by the repeated opening of the containers. 
It was for these reasons that catgut was almost 
wholly discarded in most of our leading hospitals, 
several years ago, and is even now only slowly com- 
ing into favor. Another objection to catgut was the 
liability in some instances of too rapid absorption. 

By methods of preparation and preservation 



GAUZE, SPONGES, LIGATURES, SUTURES. 83 

which have been elaborated within the past few years 
all these objections have been overcome. 

There are three reliable methods of steriHzing 
catgut. These are by boiling in ciimol, treating by 
formalin solution and afterward boiling in water, and 
by boiling in alcohol in sealed tubes under pressure 
and at a high temperature. The catgut can be ster- 
ilized with certainty by any of these methods, but it 
can be preserved in a sterile condition better when 
steriHzed in alcohol in hermetically sealed glass 
tubes. The catgut is also hardened by either of the 
other methods, and the period of absorption is 
lengthened. This may be an objection for some 
purposes, and for others it is to be desired. 

Cumol is a coal tar derivative with an exceed- 
ingly high boiling point: about 170° C, or 238° F. 
After sterilizing, the catgut is preserved in sterile 
bottles or jars, either in alcohol or benzine. Several 
years ago Dr. Howard A. Kelly discarded catgut as a 
suture and ligature material, but he has declared 
recently that the discovery of the process of steril- 
ization by cumol has made it the best suture and 
ligature material for general use. 

The preparation of catgut by the formalin 
method depends not upon the antiseptic properties 
of the formalin, but upon the fact that it hardens the 
catgut so that it may be boiled in water without 
injury. The catgut is soaked for several hours in 
a 2-per-cent. solution of formalin, and then boiled 
for half an hour in water, and preserved in alcohol. 

Dr. J. H. Carstens, of Detroit, is an ardent ad- 
vocate of catgut sterilized by the dry heat method 
of Boerckmann. The catgut is soaked in ether for 



84 



SURGICAL ASEPSIS. 



a week to remove the fat. The strands are then 
wrapped in fine tissue paper, put in an envelope, and 
sealed. These envelopes are then put in a Boerck- 
mann sterilizer and subjected to a heat of 300° F. 
for three hours on two successive days; and when 
ready to use the end of the envelope is torn off and 
the tissue paper containing the ligature is dropped 
into alcohol, from which it may be used. Catgut 




Fig. 35. — Boerckmann's Sterilizer, with Box for the Dry 
Sterilization of Catgut. 



prepared in this manner may be obtained from 
Truax, Greene & Co., of Chicago. 

An ideal method of sterilizing and preserving 
catgut is by boiling it in alcohol under pressure. 
Alcohol boils at 174° F., and that temperature is not 
sufficient to sterilize the catgut. To accomplish this 
the catgut is wound on a glass spool and placed in a 
glass tube nearly filled with alcohol. The upper end 
of this tube is hermetically sealed, and it is then 



GAUZE, SPONGES, LIGATURES, SUTURES. 85 

placed in an autoclave and subjected to a tempera- 
ture of 248° F. for an hour. As the tube is hermetic- 
ally sealed, its contents are preserved in an aseptic 
state for any length of time. If it is desired to in- 
crease the length of time required for absorption, the 
catgut may be treated with a solution of bichromate 
of potash before it is sterilized. It may also be ob- 
tained half-chromicized when it is not desirable for 
absorption to be delayed for several weeks. 

This process of sterilization is so complicated 
that it cannot be carried on by the physician, and he 
must, therefore, depend upon some reliable manu- 
facturer to prepare his sutures for him. There are 
a number of firms that prepare the catgut after this 
method, and, so far as I know, the product of all 
these is reliable. For several years I have used the 
catgut prepared by St. John Leavens, of New York, 
and can commend it as being perfectly reliable. This 
product may be had in three sizes, either plain or 
chromicized. Each tube contains one meter, or 
about thirty-nine inches, of catgut. When it is to 
be used a sufficient number of tubes are placed in a 
bowl of bichloride solution to sterilize the outside of 
the tubes. The tubes may be broken by grasping 
each end by a sterilized towel. The catgut is some- 
what stiff from the effect of the alcohol, and espe- 
cially is this true of the chromicized gut. If it is 
dropped in sterile water and allowed to remain for 
two or three minutes, it will become pliable and will 
tie more closely. As the remnants of the unused 
ligature must be discarded, only as many of the tubes 
should be broken before the operation commences as 
will certainly be required. 



86 SURGICAL ASEPSIS. 

The expense of catgut prepared in this way may 
be a vahd objection to its use in hospital practice, 
but its advantages are so great that this small item 
should not prevent its use. The danger of contami- 
nation of the contents of the receptacle, while re- 
moving the ligature for repeated operations, is not 
small, and the danger is increased by the careless- 
ness begotten by the general opinion that alcohol, 
or whatever liquid in which the ligature is preserved, 
is an antiseptic capable of destroying any germs 
which might gain access to it. It must be remem- 
bered that alcohol is not destructive to germs, but 
only inhibits their growth. It will therefore pre- 
serve, in a sterile condition, any article that has been 
completely freed from germs, but it will not act as 
a germicide. Catgut which is kept in glass tubes 
with rubber caps, and intended to be drawn from 
the tube as used, is not to be relied upon. 

Kangaroo Tendon was introduced as a suture by 
Dr. Henry O. Marcy, of Boston. He especially com- 
mended it as a suture in hernia operations on account 
of its long resistance to absorption. It may be pre- 
pared in the same manner as catgut and is furnished 
in the hermetically sealed tubes by Van Horn & Co., 
of New York, and several other houses. Its tensile 
strength is greater than that of catgut, and, since it 
consists of longitudinal bands of fibrous tissue, it can 
be divided into any desirable size. 

The process of absorption of animal ligatures 
takes place by infiltration by round cells and leuco- 
cytes, and the rapidity of the process depends largely 
upon the blood-supply of the parts. Absorption is 
most slow in the subcutaneous tissues and fascia, 



GAUZE, SPONGES, LIGATURES, SUTURES. 87 

while it is quite rapid in the skin and still more so in 
the mucous membranes. 

The length of time required for absorption in- 
creases very rapidly with the size of the catgut used. 

Dr. Hugh Cabot, of Boston, has recently ex- 
perimented quite largely with catgut buried in the 
muscular tissue of rabbits. He found that No. 2 cat- 
gut requires from two to three times as long for its 
absorption as did that of the No. 1 size. His con- 
clusions are as follows : 1. That in the flesh of rab- 
bits No. 1 chromicized catgut is retained longer than 
is desirable in a suture material for surgical use. 2. 
That plain catgut of No. 1 size is retained a suffi- 
cient length of time ; that is to say, a minimum of 
three weeks. 3. That catgut sterilized by dry heat 
is more rapidly absorbed than that prepared by the 
moist methods. 4. That the time required for ab- 
sorption increases very rapidly with the increase in 
size. 

As the different firms who prepare catgut have 
various methods of numbering the sizes. No. 2 must 
be substituted for No. 1 in his conclusions, if the 
numbering in the particular article used commences 
at No. 1. The varieties which Cabot used were num- 
bered from No. 00 up to No. 3 : a very confusing 
method. 

It follows from the foregoing that the size and 
preparation of catgut to be used should depend upon 
the time it is desired to have its strength retained, 
and the vascularity of the tissues in which it is to be 
placed. For the peritoneum and small blood-vessels 
the No. 1 size of Leavens's plain catgut will be suffi- 
cient, while for the skin and larger vessels the No. 2 



88 SURGICAL ASEPSIS. 

should be used. For the mucous membranes and 
larger arterial trunks the No. 2 chromicized or the 
No. 3 plain gut should be used, and for uniting the 
fascia of an abdominal wound or hernial opening I 
prefer the No. 1 chromicized gut on account of its 
small size, its tensile strength, and its lengthened 
resistance to absorption. 



CHAPTER VIII. 

DRAINAGE OF WOUNDS. 



It was formerly considered necessary to drain 
all abdominal wounds whether infected or not. It 
was supposed that the serous oozing which follows 
an abdominal operation must be removed or it would 
decompose and cause peritonitis. 

The experiments of Wegner and Muscatello, 
which have been cited, prove that enormous amounts 
of sterile fluids may be absorbed by the peritoneum, 
and that considerable quantities of septic material 
may also be absorbed. 

Muscatello's demonstration of the absorptive 
power of the diaphragmatic peritoneum was utilized 
by Dr. J. G. Clark in his postural drainage, and the 
absorption of septic material was increased by dilut- 
ing it with sterile salt solution. This postural drain- 
age is carried out by leaving from one to two pints 
of salt solution in the abdomen and by raising the 
foot of the bed eighteen inches. 

The knowledge of this ability of the diaphrag- 
matic peritoneum to rapidly absorb all fluids which 
are brought in contact with it may be of service in a 
class of cases in which the greatest danger is not 
from peritonitis, but from an acute toxaemia from 
the overwhelming amount of bacteria and their tox- 
ins which have gained access to the wound. These 

(89) 



90 SURGICAL ASEPSIS. 

cases should be treated in a directly opposite man- 
ner, by free drainage and by elevating the shoulders 
so that the absorption of the infectious material may 
be retarded as much as possible. 

It must be remembered that in many chronic 
suppurative cases the pus has become attenuated 
and very nearly sterile, and also that some micro- 
organisms are incapable of proliferating on the peri- 
toneal surface. This is especially the case with the 
gonococcus. It is much safer to trust the perito- 
neum to absorb and destroy small quantities of septic 
material than to trust to a badly managed drain. 

Especially is this of importance to the country 
surgeon, who must operate where he cannot have 
charge of the after-treatment, and has reason to fear 
the technique which will be carried out by the at- 
tending physician. 

It is entirely unnecessary to provide for the re- 
moval of the sero-sanguineous oozing which follows 
an abdominal operation, and the presence of any 
foreign body excites a freer flow from the wounded 
surfaces than would otherwise take place. The drain 
is usually a very inefficient means of removing fluid 
from the abdomen, as it must work against gravity 
and it often acts as a plug to cause its retention ; its 
presence gives an open door to the entrance of 
germs which may find their way into the dressings 
or may reach the wound during its dressing ; it holds 
asunder tissues which might be brought in close ap- 
position and, therefore, it increases the dangers of 
ventral hernia ; from the irritation of the peritoneal 
surfaces which it causes it favors adhesions which 
may become the cause of intestinal obstruction; from 



DRAINAGE OF WOUNDS. 91 

pressure on the intestinal coats it may cause a faecal 
fistula; the removal of a drain is always painful, as 
the gauze drain quickly becomes adherent to the 
peritoneal surfaces and portions of omentum may 
press through the openings of a glass drain. If a 
glass drain is used, it should be turned at each dress- 
ing. 

There are two classes of cases where a drain is 
indispensable. It should be used to drain abscess- 
cavities, which are shut off from the peritoneal cav- 
ity and cannot be enucleated, and in wide-spread 
peritoneal suppuration. Whenever it is possible, the 
aid of gravity should be invoked. If suppuration is 
in the pelvis it may be drained through the vagina, 
either with or without drainage through the abdom- 
inal incision. If the suppuration is in the lesser 
peritoneal pouch, either as a result of suppurative 
inflammation of the gall-bladder, liver, or pancreas, 
or from extension of an appendical abscess, the same 
result may be obtained by a lumbar incision. This 
may be made as a '^lumbar stab" from within, under 
the guidance of the fingers, or the surgeon may 
gradually dissect from without inward on to the end 
of the finger which is placed at the desired point 
inside the abdomen. Drainage is best secured, 
through a lumbar incision, by a rubber drainage 
tube. 

After a suture of the gall-bladder or its ducts, 
or after an intestinal anastomosis from which it is 
feared a leakage may take place, it is well to place 
a provisional drain, to be removed in two or three 
days if the union seems secure. 

For securing drainage, we may use glass or 



92 



SURGICAL ASEPSIS. 



rubber tubes, gauze, lamp wicking, rubber tissue, or 
a combination of these methods. 

Glass Drainage Tubes are not often used at the 
present time. They are especially useful, however, 
in draining a localized suppurating area deep in the 
abdomen, where the pressure of the abdominal con- 




Fig. 3G.— Glass Drainage Tube. 

tents would prevent drainage by gauze or wicking. 
The tubes are usually curved, and should be from 
V4 to V2 ii^ch in diameter, and from 4 to 6 inches 
in length. The fenestra should not be more than 
V20 oi* V25 inch in diameter. When they are larger 
than this, minute hernise of the omentum are apt to 
occur through the openings. 







ifff^B^^asTff^F^^assSsfg^^ 



Fig. 37. — Murphy's Glass Drainage Tubes. 

In order for a tubular drain to be effective, it 
must be frequently cleansed or it may be supple- 
mented by gauze drainage within the lumen of the 
tube or beside it. The capillary attraction of a lamp 
wick which loosely fills the tube and communicates 
with a copious absorbent dressing greatly assists the 



DRAINAGE OF WOUNDS. 93 

drainage. If this is not used, the best method of 
removing the Hquids which fill the tube is by means 
of pledgets of sterile absorbent cotton held in slender 
forceps, or by a suitable suction syringe. 

If there is much oozing, this cleansing will be 
necessary every twelve or twenty-four hours and 
must be done with as strict regard to asepsis as is 



Fig. 38. — Slender Forceps for Drainage Tube. 

the original operation. The glass drainage tube may 
be boiled, or it may be sterihzed by immersion in 
solution of bichloride of mercury 1 to 500 for one- 
half hour. 

The Rubber Drainage Tube is more often used 
than glass on account of its flexibility, and the fact 
that it may be cut of the desired length. From its 




Fig. 39.— Hard-Rubber Syringe for Cleansing Drainage Tube. 

flexibility it may be carried into a cavity in any direc- 
tion, and is less Hable to cause gangrene of the in- 
testine and fsecal fistula than is the glass tube. It 
may be had in sizes from three-sixteenths to one- 
half of an inch in diameter, or ordinary rubber tubing 
of the desired size may be fenestrated at intervals 
of one-third of an inch. If the drainage tube has 



94 



SURGICAL ASEPSIS. 



been omitted in the list of articles to be provided, 
one may always be made from a piece of the tubing 
of the fountain syringe. The tube may be sterilized 
in the same manner as the glass tube, but best by 
boihng for five minutes. The same principles apply 
to the cleansing of the tube as to the glass drains. 




Fig. 40. — Rubber Drainage Tubes. 

All the remaining varieties of drains act by cap- 
illary force, and much of their efficiency depends 
upon their communication with an absorbent dress- 
ing which is changed so often as never to be sat- 
urated. In order to obtain the full benefit of cap- 
illary drainage it is necessary to employ a small 




Fig. 41. — Hamilton's Drainage Tube Carrier. 

drawing column of absorbent material in the interior 
of the wound, with a large receiving mass of absorb- 
ent material placed in contact with it, outside the 
wound. - The receiving mass must be changed when 
it becomes saturated to the point of decreased ab- 
sorbing power, otherwise it will have little effect 
upon the drawing column within. 



i 



DRAINAGE OF WOUNDS. 95 

Gauze Drains may be made either of plain sterile 
gauze or of iodoform gauze. It is usually better to 
follow the simple aseptic rules and use no chemical 
disinfectants. The gauze strips may be used in any 
length and width to suit the operator, and to accom- 
plish the end he has in view. 

The most convenient way is generally to use a 
strip, cut from one and one-half to two inches in 
width and from eighteen to twenty-four inches long. 
This is folded twice and stitched along the edge. 
When it is inserted, it should be so packed in the 
cavity to be drained that in its removal it will not 
become entangled and cause injury to the granulat- 
ing tissues. This may be accomplished by packing 
the gauze strip around the cavity to be drained, and, 
last, the center of the cavity, so that, as the strip is 
withdrawn, it will unfold, much as when a ball of 
twine is unrolled from the inside of the ball. Great 
care must be exercised, lest the gauze is packed so 
tightly in the opening of the abdominal wall that it 
act as a plug and cause retention of the fluids which 
it is intended to remove. 

Sometimes it will be necessary to terminate an 
operation quickly and before perfect control of haem- 
orrhage from a large denuded surface has been se- 
cured. Gauze packing may be used with consider- 
able pressure to accomplish this. When used in this 
way, it is well to line the cavity to be packed by a 
single layer of gauze and then pack the strips into 
this as a bag would be filled. When the packing is 
to be removed the strips may be pulled out one by 
one, and finally the gauze lining the cavity may be 
removed. 



96 SURGICAL ASEPSIS. 

The Mikulicz gauze drain is made in the man- 
ner I have just described, only the gauze strips are 
packed loosely. 

Lamp Wicking may be used instead of gauze, and 
should be inserted in the same manner. Dr. Robert 
T. Morris uses what he calls the gause wick drain. 
It is made of a strip of gauze which, when loosely 
folded, is about as large as a lead pencil, and this 
strip of gauze is rolled in gutta-percha tissue much 
as one would roll a cigarette. The gauze projects 
at each end a little beyond the rubber tissue, and 
small openings are snipped in the gutta-percha cov- 
ering, after it has been rolled, so that fluids can enter 
at more than one point. The gutta-percha covering 
prevents the adhesion of the gauze to the peritoneal 
surfaces, and, by directing the current, it increases 
the capillary attraction of the gauze. The gauze 
strip should be sterilized by steam, and the gutta- 
percha tissue by immersion in a 1 to 500 solution 
of bichloride of mercury for an hour. This solution 
should be cold. 

The gutta-percha tissue alone makes a very 
good drain when simply folded in several thick- ' 
nesses. Its capillarity is not great, but it serves to 
keep the wound open and forms a smooth plane 
along which the fluids find their way to the surface, 
following the line of the least resistance. 

Removal of Drains. — As soon as the objects of 
drainage have been accomplished the drain should 
be removed. If an abscess-cavity is to be drained, 
it is usually safe to remove the drain in a few days, 
and simply keep the external opening patent by 
loosely packing with sterile gauze, or by a strip of 



DRAINAGE OF WOUNDS. 97 

rubber tissue. The walls of the cavity to be drained 
quickly fall together from the pressure of the in- 
testinal coils, and the fluids are forced out of the 
opening. A persistent sinus is often caused by al- 
lowing the drainage tube to remain too long or by 
too persistent packing of the cavity to its bottom. 



CHAPTER IX. 

DRESSING OF WOUNDS. 



The objects of surgical dressings are to protect 
the wound from mechanical injury, to prevent the 
entrance of germs from without, and to absorb the 
discharges from the wound. If the wound is closed 
without drainage, the first two objects are the prin- 
cipal ones. 

If drainage is used or if much oozing from the 
wound is to be expected, an abundant absorbent 
dressing must be used. The principal dressing mate- 
rials, which are now almost universally used, are 
absorbent gauze, absorbent cotton, cotton wadding, 
and the various medicated gauzes. Some surgeons 
also use oakum. Absorbent gauze and cotton an- 
swer all the requirements for a good dressing and 
no other materials are necessary. In the absence 
of these, clean linen or cotton cloth miay be steril- 
ized and used in their place. Sometimes the medi- 
cated gauzes, iodoform, sublimate, carbolic acid, or 
formalin may be used. 

The dressing may be mad-e by placing a layer 
of absorbent cotton between two layers of gauze, 
stitched about the edges, or several layers of gauze 
may be placed next the wound and covered by a suf- 
ficient amount of cotton to absorb all discharges 
from it. If the wound must be drained, or is one 
from which much oozing may be expected, a suffi- 
(98) 



DRESSING OF WOUNDS. 99 

cient amount of dressing must be used so that it 
will not become saturated. 

If the discharges wet through the dressing, 
conditions become favorable for the development 
of bacteria in it and consequent infection of the 
wound. 

An Occlusive Dressing may be used if drainage 
is not necessary. This successfully protects the 
wound from mechanical irritation and from infec- 
tion from without. It is especially useful in places 
where the wound cannot be well protected by ordi- 
nary dressings. It is to be commended in harelip 
operations, in operations for hernia, Alexander's 
operation, suprapubic cystotomy, and symphysiot- 
omy. The only objection to its use is the difficulty 
in removing it. If Halsted's subcutaneous suture 
is used, the dressing may be allowed to remain until 
it becomes loosened. It must be carefully watched, 
however, to make certain that there is no suppura- 
tion beneath it. If it is necessary to remove it, it 
may be softened by applying a pledget of cotton 
saturated with equal parts of absolute alcohol and 
ether. The occlusive dressing is made by applying 
several layers of gauze saturated with collodion or 
celloidin. 

Celloidin may be made by the following for- 
mula : — 

IJ Squibb's ether, 

Absolute alcohol, of each, 50.00 cubic centimeters. — M. 

Add gun-cotton slowly until the mixture is of 
the consistency of simple syrup. If it is desired to 
add some antiseptic, 6.25 grammes of iodoform may 
LofC. 



100 SURGICAL ASEPSIS. 

be added or 0.25 cubic centimeter of the following 
solution : — 

IJ Cryst. hydrarg. bichloridi, 1.00 gramme. 

Absolute alcohol, 40.00 cubic centimeters, — M. 

The best method of applying this dressing is 
as follows : After the wound has been thoroughly 
dried, a piece of sterile gauze or crape cloth is 
placed over it. Upon this is poured some of the 
celloidin and distributed over the surface by a glass 
or steel spatula. Over this is placed another layer 
of the gauze and celloidin and finally the ordinary 
dressing. As there is no necessity for an absorbent 
dressing, the cotton wadding makes an excellent 
covering. 

Bandages are used to retain dressings in place 
and sometimes to exert pressure. If only for the 
retention of dressings, some light material like 
gauze is best. If much pressure or firmness is de- 
sired, they may be made of muslin, cotton flannel, 
or wool. 

Wounds of the extremities, head, neck, and 
some parts of the trunk are covered by the roller 
bandage. Gauze or muslin bandages of any desired 
width may be purchased or may be cut by drawn 
thread. 

For abdominal wounds, the simple straight 
binder, the T-bandage, or the Scultetus bandage 
may be used. If the simple binder is used, it is 
very apt to slip up, and should be held in place by 
a strip of cloth passed around each thigh and pinned 
to the lower part of the bandage over each tro- 
chanter. 



DRESSING OF WOUNDS. 101 

The Scultetus bandage is made of eight pieces 
of cloth, each four inches wide and from twenty to 
thirty inches in length, according to the size of the 
patient. Six of the strips are laid edge to edge, 
each strip overlapping the next by one-half its width, 
and sewed to two perineal strips crossing the ab- 
dominal strips at right angles in their center. 

This bandage is applied by crossing the upper 
straps diagonally downward over the abdomen so 
that they will He flat. The next two straps, when 
crossed, will overlap these, while the lower one will 
pin straight across. Only the lower straps need be 
pinned. The abdominal straps are held in place by 
the perineal straps, which are drawn firmly between 
the thighs. 

All abdominal bandages should be made of 
some material which is not heavy enough to be un- 
comfortably warm to the patient, but firm enough 
to exercise some pressure. If it is of loose texture, 
it is much more easily pinned. The best material is 
thin, white, cotton flannel, sometimes called outing 
flannel. 



CHAPTER X. 

PREPARATION FOR OPERATION BY THE NURSE. 



That a faultless technique may be carried out, 
it is necessary that the preparation be made in a 
methodical manner, so that each step prepares for 
the next. It is also necessary that the nurse should 
understand the method of the surgeon, lest confu- 
sion and uncertainty should result. 

At the risk of appearing somewhat pedantic, a 
plan of preparation will be outlined, both for the 
nurse and the surgeon and his assistants. 

It will be assumed that an abdominal opera- 
tion is to be performed in a well-furnished private 
house and with the aid of a professional nurse. If 
it should be impossible to secure an efficient nurse, 
a part of the preparation may be intrusted to some 
intelligent woman, while the most essential part of 
the preparation must be made by the surgeon him- 
self, or by a trustworthy assistant. 

Should it be impossible to secure everything 
to be desired, the ingenuity of the operator will 
furnish some substitute. 

We will suppose that the operation is to be 
performed at 9 a.m. The nurse should be in attend- 
ance, when possible, at least twenty-four hours be- 
fore the time appointed. She should be furnished 
by the surgeon with a written list of the number of 
tables, towels, sheets, basins, and all other articles 
(102) 



PREPARATION BY NURSE. 103 

which he will require. If she is not familiar with 
his particular method, he should instruct her in re- 
gard to the principal details. Unless this is done, 
confusion and uncertainty may result from a prep- 
aration which may be equally thorough, but not 
adapted to the methods of the surgeon. 

The nurse will be very grateful for these sug- 
gestions if she is not given the impression that the 
surgeon considers all other methods defective. The 
first duty of the nurse should be to secure all the 
articles in the Hst suppHed by the surgeon. She 
should then superintend the preparation of the op- 
erating room; make the gauze sponges, dressings, 
and bandages; and make up the packages for the 
sterilizer. 

After the room is prepared and the operating 
furniture is disinfected, everything which is to be 
sterilized by steam may be sterilized and placed on 
a table in the operating room. 

The water to be steriHzed and cooled should 
be boiled the night preceding the operation and set 
away in the operating room. 

Early in the evening the patient should be 
given a cathartic, preferably an active saline. If 
the urine has not already been examined, the nurse 
should secure a sample, by catheter, if the patient 
is a female. 

Unless the condition of the patient contra- 
indicates it, he should be given a full bath. The 
abdomen is then shaved, scrubbed with soap and 
water, and covered by a thick dressing wet in a 
solution of bichloride of mercury of a strength of 1 
to 2000, This pack should be covered by some im- 



104 SURGICAL ASEPSIS. 

pervious material like rubber tissue or oiled silk to 
prevent evaporation. The rubber tissue may be re- 
placed by a piece of oil cloth or oiled paper. 

A glass of milk or malted milk may be given 
the patient at midnight, but no nourishment should 
be given after that time. 

The morning before the operation is a very 
busy one for the nurse, and she should have the 
assistance of another nurse or capable assistant if 
possible. One of these may make the operating 
room preparation while the other prepares the pa- 
tient. 

The operating roorn nurse may now sterilize the 
basins, pitchers, irrigator, etc. Two kettles of hot, 
sterile water should be reserved for the operation 
and placed in the operating room. There should 
also be plenty of hot, sterile water for the use of 
the surgeon and his assistants, to be used for the 
cleansing of the hands and for preparing the solu- 
tions. This water may be boiled in a large kettle 
or a clean wash-boiler. A pitcher or basin must be 
used for dipping the water from the boiler, and 
must be sterilized outside as well as inside, and 
when not in use should be placed on a sterilized 
dinner plate, and not set on any unsterilized sur- 
face. The solutions for the disinfection of the 
hands should be prepared and placed on a table or 
in a sink in the order in which they are to be used. 
The concentrated salt solution should be sterilized. 

After the arrival of the surgeon the operating 
room nurse may sterilize the instruments and aid 
the surgeon in his preparation. She now has her 
hands partially disinfected by soap and water and 




o 
o 
a:: 

c 



o 



PREPARATION BY NURSE. 105 

bichloride solution, but as she will be obliged to 
touch many articles which are not sterile, she should 
avoid contact with all sterile articles. 

In opening the sterile packages she should only 
draw the pins and lay the wrapper open. She 
should not put the sterile towels on the instrument 
table. After the patient is brought to the operating 
room she should remove the abdominal dressing, 
and bring the solutions to be used in the final prep- 
aration of the abdomen. 

During the operation she may take charge of 
the solutions- and change the sterile water for 
sponging, or assist in any other way the surgeon 
may desire. 

While these preparations are being made in 
the operating room, the patient is being prepared. 
An hour before the operation he should be given 
an enema of soap and water, regardless of the ac- 
tion of the cathartic. Just before the etherization 
is commenced the bladder should be emptied, by 
catheter if necessary. To avoid all errors, it is best 
always to employ the catheter. Often the bladder 
is not completely emptied, and its distension in- 
creases the danger of injury to this organ. Some 
first-class men have also reported errors of diag- 
nosis caused by a distended bladder. The limbs 
should then be wrapped in a warm blanket, which 
is well pinned so that it will not become disarranged 
during the etherization. 

If the nurse is competent she may give the 
anaesthetic, or assist with the sponges or in any 
other place desired. If the nurse can have no as- 
sistance, she will be obliged to divide her time 



106 SURGICAL ASEPSIS. 

between the operating room and the patient. In 
case the surgeon is obliged to operate without the 
assistance of any trained nurse, he should give ex- 
plicit directions to some intelligent person for the 
preparation of the room and general preparation 
of the patient, and must personally attend to the 
aseptic preparations, unless he may be fortunate 
enough to have a trustworthy assistant. 



CHAPTER XI. 

ORGANIZATION FOR OPERATION. 



To DO the best work, the surgeon should have 
assistants who thoroughly understand the princi- 
ples of aseptic work, and who have had experience 
in working together, that each may understand his 
exact duties. 

When these may be had, two or three assist- 
ants in addition to the anaesthetist are useful. Of 
these, one may assist at the wound, a second may 
take charge of the sponges, and the third may at- 
tend to the instruments and ligatures. 

If thoroughly reliable assistants cannot be ob- 
tained, the danger of sepsis is increased in propor- 
tion to the number employed. Almost any opera- 
tion may be performed with a single assistant, and 
the risk of a slightly prolonged operation is to be 
preferred to that of sepsis. 

The instrument table may be placed within easy 
reach of the surgeon, while his assistant may both 
assist him at the wound and may do the sponging. 
A single assistant is so completely under the ob- 
servation of the surgeon that an error would be de- 
tected, but it would be impossible to watch several. 

The surgeon and his assistants should arrive at 
least half an hour before the operation is to begin. 
The surgeon should see that nothing has been 
omitted in the preparation, and that the operating 

(107) 



108 SURGICAL ASEPSIS. 

room furniture is arranged in the way he desires. 
The operating table should be so placed that neither 
the operator nor his assistants will stand in his light, 
and that there shall be plenty of room on all sides. 

The surgeon will stand on the right side of the 
patient, and a table for the instruments and liga- 
tures should be placed on the same side, within easy 
reach. His first assistant will, of course, stand on 
the opposite side, and near him should be placed 
a table for the sterile towels, sponges, and dress- 
ings. The bowls of sterile water should also be 
placed on that side of the table. Another table 
should be reserved for other sterile articles to be 
used as required. A chair or table should be placed 
near the etherizer, upon which may be placed the 
ether, hypodermic syringe, stimulants, tongue for- 
ceps, and mouth-gag. A bowl of solution of bi- 
chloride of mercury should be so placed as to be 
convenient for immersing the hands during the op- 
eration. 

After the operating room is arranged the sur- 
geon and his assistants disinfect the hands and fore- 
arms. 

It is a good plan for the surgeon to precede 
in this work, and for the assistants to follow step 
by step. In this way each assistant will spend as 
much time in the process as does the surgeon. The 
operating suits are now put on, and also the rubber 
gloves if they are to be worn. The surgeon or one 
of his assistants may now cover the tables, for the 
instruments and sponges, with sterile towels, and 
then may arrange the instruments and ligatures. 
The glass tubes containing the ligatures are to be 



ORGANIZATION FOR OPERATION. 109 

broken by grasping the ends by a sterile towel. 
After the instruments are arranged, it is well to 
cover them by a sterile towel until the operation 
commences, to avoid any possible contamination. 
While these preparations are being made, the pa- 
tient is anesthetized and brought to the operating 
table. None of the assistants who are to take part 
in the operation should assist in this. 

One of the assistants now makes the final 
preparation of the patient. If the operation is to 
be a hysterectomy, or if it is possible that drainage 
through the vagina will be desirable, it should be 
disinfected first and then the abdomen. If this as- 
sistant is to take any further part in the operation 
he must sterilize his hands again with the same care 
that he did at first. Instead of this he may wear 
rubber gloves while making the preparation and 
may simply immerse the hands in bichloride solu- 
tion after their removal. 

The body of the patient, excepting the field of 
operation, and the operating table is now completely 
covered by sterile sheets and towels. 

One sterile sheet reaches from the pubes down 
over the foot of the table and overhangs at the 
sides. Another reaches from the neck to the upper 
limit of the field. At the sides of the abdomen 
towels are pinned to these sheets. Instead of this 
arrangement a laparotomy sheet may be used, with 
an opening in the center. 

It is a matter of prime importance that the 
table should be completely covered. It prevents 
the unconscious contact of the surgeon and his as- 
sistants with unsterilized surfaces and furnishes a 



110 SURGICAL ASEPSIS. 

convenient resting place for instruments during the 
operation. 

Should the surgeon be obUged to touch any 
object which cannot be completely sterilized, as the 
thermocautery, he may grasp it with a piece of 
sterile gauze, which must be immediately discarded. 

During the operation constant watchfulness is 
necessary that those who are connected with it shall 
not contaminate their hands. I am in the habit of 
requesting my assistants to call my attention to 
any unconscious act of myself, or of the other as- 
sistants, which might endanger the result. When 
a perfect result, and possibly the safety of the pa- 
tient is at stake, that which is sometimes called 
^'professional courtesy" should not be fostered. 



CHAPTER XIL 

PERITONEAL TOILET; SUTURING AND DRESSING 
THE WOUND. 



It is now the purpose to discuss methods of 
operating only so far as they bear upon the devel- 
opment of sepsis in the wound. Bruised tissues 
and stagnant fluids, in a wound, favor the develop- 
ment of sepsis, by furnishing a pabulum for what- 
ever germs have gained entrance. Therefore clean 
incisions, care regarding the bruising of the tissues 
by retractors and clamps, and perfect hsemostasis 
are essentials to a good operation. 

In cases where a pus-cavity or cyst is present 
in the abdomen, the danger of infecting the whole 
peritoneal cavity should be reduced to the minimum 
by "walling off" the infected area before the abscess 
or cyst is disturbed, for fear of rupturing it. To 
wall off the peritoneal cavity properly the intestines 
should be pressed away from the diseased tissues 
as far as possible by the fingers, "and several thick- 
nesses of sterile gauze packed tightly about the dis- 
eased area in every direction. The attempt should 
then be made to aspirate the septic fluid, to pre- 
vent, as much as possible, saturating the gauze. 

After the infected tissue has been enucleated 
or washed out thoroughly the surgeon should 
cleanse his hands by soap and water and bichloride 
solution, and any instruments which have been con- 

• - (111) 



112 SURGICAL ASEPSIS. 

taminated should be discarded or resterilized before 
the operation continues. 

If irrigation is used to wash out the septic 
material, the nozzle must pass down to the bottom 
of the cavity, under the guidance of the fingers. 

Before the abdomen is closed the cavity should 
be thoroughly sponged out by dry sponges held in 
forceps. If a rule is always made never to intro- 
duce a sponge into the abdomen unless it is held 
by forceps, and to leave one end of every piece of 
gauze used protruding from the wound, there need 
never be any danger of losing a sponge in the 
abdomen. 

Fluid is most apt to collect in the cul-de-sac 
behind the uterus. To remove this, the body of 
the uterus should be held forward by two fingers 
while the sponge is carried down into Douglas's 
pouch. Care should be taken, in sponging, that the 
peritoneal surface is not injured by wiping its sur- 
face and that the ligatures are not loosened. After 
the peritoneum is dry all Hgatures should be in- 
spected. 

If there has been infection and it is desired to 
employ the postural method of drainage through 
the peritoneal surfaces, from one to two pints of 
normal salt solution may be poured into the abdo- 
men. 

Before the wound is closed the intestines should 
be allowed to fall into place and the omentum should 
be drawn down over them to prevent adhesions to 
the parietal peritoneum. 

Dr. Charles H. Cargile, of Bentonville, Ark., 
has made use of what he terms ''sterilized animal 



PERITONEAL TOILET. 113 

membrane" for covering areas which cannot be cov- 
ered with peritoneum, and thus Hmit the formation 
of adhesions. This membrane is a very thin gold- 
beater's skin, made from the peritoneum of the ox. 
It is asepticized by boihng in cumol, and can be ob- 
tained from Johnson & Johnson in the form of folded 
sheets in a sealed paper package. There would be 
less danger of its contamination during its prepara- 
tion, packing, and use if it were sterilized in alcohol 
in sealed tubes and under pressure. 

Dr. Robert T. Morris, who has for many years 
taught the use of the aristol film over the peritoneal 
surfaces to prevent adhesions, has used this mem- 
brane clinically with success. He has also conducted 
a number of experiments with rabbits, to determine 
its utility and the rapidity with which it is absorbed. 

As a result of the clinical use and experiments, 
Dr. Morris concludes that the membrane resists ab- 
sorption in the abdominal cavity for more than ten 
and less than thirty days. Its presence apparently 
causes the formation of temporary loose adhesions, 
which are harmless and which become absorbed in 
most part in less than thirty days. The membrane 
seems to cause very little disturbance to the perito- 
neum, it does not furnish a good culture medium for 
bacteria, and it protects areas of peritoneal surface 
that have suffered injury to their endothelial cells 
until new endothelial cells have repaired the injury. 
It is not necessary to suture the membrane in place, 
as it becomes instantly adherent to moist surfaces, 
and is not readily dislodged afterward. For this rea- 
son it cannot be well handled with \\^et hands or in- 
struments. 

8 



114 SURGICAL ASEPSIS. 

It seems from these experiments that we have 
in the "steriUzed animal membrane" of Dr. Cargile 
a very valuable resource. In addition to its use for 
covering in areas which have been denuded of peri- 
toneum it may be used to cover the line of sutures 
of an intestinal anastomosis, to cover open wounds, 
and as a protective for skin-grafts. 

Suture of the Wound. — The healing of a wound 
may be much influenced by the method of closing 
it. To insure immediate union the wound must not 
only be aseptic, and remain so, but the edges must 
be accurately sutured. 

There is a great diversity of opinion among 
surgeons regarding the best method of closing ab- 
dominal wounds. Many use a suture down through 
all the tissues into the peritoneal cavity. This 
through and through suture is usually of silk or silk- 
worm gut, and should remain for ten or twelve days. 
When we were unable to secure reliable absorbable 
sutures, this method was necessary. When it is 
not necessary, on account of the condition of the 
patient, to conclude the operation quickly, the su- 
ture of the structures, layer by layer, is much to be 
preferred. By use of this method all the structures 
are brought together in their correct anatomical 
relations. By the use of absorbable sutures through 
the muscular and tendinous structures, which will 
resist absorption for twenty or thirty days, the cut 
surfaces are kept in apposition while the plastic 
reparative lymph is replaced by normal tissue cells. 
Most important of all is the shutting off of the 
peritoneal cavity, should any of the skin sutures 
become infected. It will be readily seen that stitch 



PERITONEAL TOILET. 115 

infection may follow down along the suture into 
the peritoneal cavity if the through and through 
stitch is used. As the skin nearly always harbors 
the staphylococcus epidermidis alhiis in its deeper layers, 
infection may also be carried into the peritoneum 
as the suture is drawn through in its removal. 

If the suture by layers is used, the peritoneum 
is united by a continuous suture of fine, sterile cat- 
gut. The muscular or tendinous structures are then 
brought together with fine, chromicized catgut. If 
there is a thick layer of adipose tissue, this should 
be sutured lightly with sterile catgut to prevent 
haematoma from the oozing. The skin may be su- 
tured with catgut, silk-worm gut, or silk. If catgut 
is used the continuous suture,, or the subcutaneous 
suture of Halsted, is best. 

If catgut is used for the subcutaneous suture. 
No. 1 plain gut should be selected. The first stitch 
is made to encircle some of the subcutaneous tissue 
beyond the angle of the wound, and is tied. The 
stitch is then passed alternately through the tissue 
from side to side, and, when the other angle of the 
wound is reached, the suture is drawn tightly 
enough to approximate the margins of the wound, 
and tied. Silk-worm gut is better than catgut for 
this suture. A strand of large size should be se- 
lected. The needle should be introduced one-third 
or one-half inch beyond the angle of the wound 
and brought out at the angle. The suture is then 
introduced in the manner described, but is brought 
out at the other angle in the same manner as com- 
menced, and the ends are left an inch long and not 
tied. Silk-worm gut is almost an ideal suture for 



116 SURGICAL ASEPSIS. 

the skin. Unless there is great tension, it is only- 
necessary to make the first half of the surgeon's 
knot. From the stiffness of the material the ends 
will lie flat against the surface and hold the tissues 
with only the double twist. If any suture is too 
tightly or too loosely drawn it may be adjusted at 
any time. The skin sutures should not include any 
of the adipose tissue, as this will quickly yield, and 
in a day or two the sutures will be found loose and 
the skin margins not in good apposition. On ac- 
count of the saving of time, the through and through 
suture must sometimes be used. Silk-worm gut is 




Fig. 43.— Powell's Suture Button. 

best for this purpose. It requires some skill and 
experience so to place the sutures that the tissues 
shall be brought together in their correct anatomical 
relations. 

The mattress suture is sometimes of use when 
there is much tension on the sutures. This some- 
times occurs in operations for umbilical hernia, or 
after a large amount of tissue has been removed, 
as in excision of the breast. It should be of silk- 
worm gut and should be deeply passed into the tis- 
sues, an inch or more from the margins of the 
wound, and brought out at a corresponding dis- 
tance on the other side. 



PERITONEAL TOILET. IIT 

The suture should be carried through double, 
and the looped end cut. The ends should then be 
secured by a Powell button or they may be passed 
through the openings of a common agate button, 
drawn tightly enough to take the tension off the 
margins of the wound, and tied. Irritation of the 
skin, from the pressure of the buttons, may be pre- 
vented by drawing a piece of gauze under the 
button. Instead of using the buttons, the sutures 
may be tied over short pieces of rubber tubing. 

Dressing the Wound. — After the sutures are tied 
the abdomen should be cleansed from blood by 
washing with sterile water or bichloride solution. 
It is best first to cleanse the portion about the in- 
cision, cover this by a piece of sterile gauze, and 
then cleanse the remainder of the abdomen. The 
sponge should never be used on the margins of 
the sterilized area and then used on the wound. 

The incision itself may be covered by rubber 
tissue to prevent the adhesion of the gauze to the 
wound. If this is not used, adhesion may be pre- 
vented by dusting with aristol. The powder should 
be poured from a bottle on a pledget of sterile 
cotton used as a powder puff. 

If a drainage tube is used, care must be taken 
that the dressing does not press too hard on the 
end of the tube. Should the glass tube be used, it 
might cause intestinal perforation from the press- 
ure. A large piece of gauze may be laid around 
the tube in the form of a wreath, and over this the 
ordinary dressings may be placed. 

The dressing should be held in place by two 
or three strips of rubber adhesive plaster placed 



118 SURGICAL ASEPSIS. 

across it and long enough to reach well around 
upon each flank. When the dressing is to be 
changed, these strips may be cut in the center and 
the ends laid back, but not removed from the skin. 
After the fresh dressing has been applied, the ends 
of the straps may be fastened together by tapes 
passed through openings snipped in the ends of the 
plaster. Over all these the abdominal bandage is 
tightly pinned, and the patient is transferred to the 
bed. 



CHAPTER XIII. 

AFTER=TREATMENT. 



The room to which the patient is removed 
should be heated to a temperature of about 80° F., 
but should be well ventilated. The bed should be 
previously warmed by hot-water bottles or by iron- 
ing over with a hot flat-iron. The hot bottles 
should be placed at the patient's feet, and, if there 
is much depression, should be placed in the axillae 
and about the body. Great caution is necessary to 
avoid burning the patient. 

If there has been much loss of blood or de- 
pression of the circulation, a pint or more of nor- 
mal salt solution should be thrown into the rectum. 
To this may be added whisky or meat extract if 
desired. 

Shock is due in great measure to a temporary 
paralysis of the vasomotor nerves of the blood- 
vessels of the abdomen. This allows the vessels to 
dilate, and a large amount of blood is withdrawn 
from the general circulation. The best way to 
combat shock is to fill the vascular system to re- 
pletion by some fluid. If the symptoms are urgent 
the fluid should be introduced into the cellular tis- 
sue or into a vein. Venous transfusion will not 
often be used on account of some of its dangers 
and the absence of proper apparatus. 

A considerable amount of salt solution may 

(119) 



120 



SURGICAL ASEPSIS. 



be rapidly introduced into the cellular tissue, and 
quickly finds its way into the circulation. A large 
aspirating needle should be connected with the ir- 
rigator tube and the fluid slowly injected into some 
portion of the body where the skin is loose and 
the cellular tissue abundant. The most favorable 
place is under the breast. The fluid should be in- 
troduced at several points, as too great pressure 
may endanger the vitality of the tissues and cause 
a large abscess. At the same time, stimulation of 




Fig. 44. — Webster's Needles for Hypodermoclysis. 

the heart by strychnia hypodermically and whisky 
by the rectum may be used. If a sufficient quan- 
tity of the salt solution is not retained by the 
rectum, the following stimulating enema may be 
used : — 

I^ Spt. vini Gallici, 
Black coffee, 
Normal salt solution, of each, 2 ounces. — M. 



Excessive Vomiting is very distressing to the 
patient. The head should be kept low, and when 



AFTER-TREATMENT. 121 

vomiting occurs it should be turned to the side 
and a shallow basin should be at hand to receive 
the vomitus. The nausea usually passes off in from 
twenty-four to forty-eight hours. Sips of very hot 
water occasionally relieve it and also the extreme 
thirst which is always present. If the hot water is 
rejected, the lips may be wet by means of absorb- 
ent cotton wound on a toothpick and wet with 
cold water. No cold water should be taken into 
the stomach while the vomiting continues. 

Small quantities of iced champagne may be of 




Fig. 45.— Eectal Tube. 

benefit. If the nausea is persistent, the patient 
must be nourished by rectal enemata of beef juice 
or peptonized milk. If the nausea has subsided 
after eighteen or twenty-four hours, liquid nourish- 
ment — like peptonized or malted milk, tgg albumin 
with brandy, or meat extract — may be given, ^/a 
ounce every two hours. In another twenty-four 
hours milk and lime-water may be allowed, and 
after the third or fourth day a variety of soft food. 
Morphia should be used only when the pain is 
very severe, since it checks peristalsis and delays 



122 SURGICAL ASEPSIS. 

the passing of flatus. It is well to tell the patient 
before the operation that the pain will be quite 
severe for a few hours, but will be relieved when 
he can pass the gas. 

I usually promise that he may have morphia 
if the pain is extreme and appeal to the fortitude 
of the patient. By this means patients are often 
seen who do not even ask for it. Much of the 
pain, after an abdominal section, is due to disten- 
sion resulting from paresis of the intestines. This 
may be relieved temporarily by passing a long 
rubber rectal tube. If this is not successful, the 
bowel may be stimulated to expel the gas by an 
injection of 1 ounce of milk of asafoetida and 2 
ounces of milk, or by 20 grains of quinine sulphate 
in 2 ounces of water. 

After twenty-four hours the patient should be 
given a laxative. One or 2 grains of calomel 
may be given, and followed on the morning of the 
third day by a Sedlitz powder, in divided doses if 
the stom^ach is irritable. If this is not retained or 
is ineffective, an enema of 1 ounce of magnesium 
sulphate, dissolved in 5 or 6 ounces of water, may 
be given slowly through the long rectal tube. The 
patient should be requested . to retain this for an 
hour or two if possible, and if it has not acted by 
this time it may be repeated. 

The commonly used mixture of Epsom salts, 
glycerin, and water is not a logical prescription. 
The glycerin which it contains is intended to stim- 
ulate the rectum to immediate action. If it does 
this, the cathartic effect of the salts is not obtained, 
as there is no time for absorption. After the 



AFTER-TREATMENT. 123 

bowels have been moved it is rare for the patient 
to suffer any considerable amount of pain. 

Catheterization after an abdominal section is 
usually necessary. The secretion of urine is usu- 
ally much diminished and it is not necessary to use 
the catheter oftener than once in eight or twelve 
hours. Extreme care should be used lest the blad- 
der be infected by its use, and it should be aban- 
doned as early as possible. 

As soon as the nausea has subsided the pa- 
tient may be allowed to take the most comfortable 
position in the bed. It will relieve the backache 
to be turned toward the side and have the back 
bathed with tepid alcohol and water. Pillows be- 
neath the knees will relieve some of the tension of 
the abdominal muscles. The weight of the cloth- 
ing should be taken from the abdomen and limbs 
by means of a bed cradle. This may be made by 
half barrel hoops nailed to a strip of board on each 
side. Instead of barrel hoops, pieces of strong wire 
bent like croquet wickets and the ends inserted 
into holes bored in the side pieces, makes a satisfac- 
tory bed cradle. 

Removal of Sutures. — If the wound has not been 
drained it will not be necessary to change the 
dressing for a week or ten days unless it becomes 
saturated or the symptoms indicate suppuration. 
At the first dressing the wound will have become 
well united, but the union will be weak. One-half 
of the stitches may be removed if desired, or they 
may all be left for ten or twelve days. There is 
nothing to be gained by early removal, and if re- 



124 SURGICAL ASEPSIS. 

moved too early the newly formed tissues yield 
to the traction and a wide scar results. 

If the abdominal wall has been closed by lay- 
ers, the patient may safely sit up in bed by the 
sixth or seventh day in most cases and sit in a 
chair at the end of ten days or of two weeks. If 
the operation has been for hernia, and the patient 
is very fleshy, or if the incision has been unusually 
long, he should be kept in bed for another week. 




Fig. 46. — Dirigo Abdominal Supporter. 

Temperature. — In normal and uncomplicated 
cases there is always some rise in the temperature, 
usually to 100° or 101° F. during the second day, 
gradually subsiding to normal by the third or fourth 
day, with a very slight rise in the afternoon. If the 
temperature remains above 100° F. or if after three 
or four days a chill occurs, followed by a rise in 
temperature, infection should be suspected and the 
dressings removed. If any hard or reddened area 
is found on either side of the wound, the stitch 
should be removed and the wound slightly pulled 



AFTER-TREATMENT. 125 

apart at that point to favor the escape of any dis- 
charge. It may also be necessary to make a small 
incision. When a stitch is to be removed on ac- 
count of a stitch abscess, it should be cut on the 
side opposite that infected, and traction made on 
the infected side. 

A hght abdominal bandage gives comfort and 
may be worn for several months. One made of 
elastic webbing and laced in the back is cool, light, 
and adjustable. 



CHAPTER XIV. 

VAGINAL OPERATIONS. 



Operations about the vagina or rectum can 
hardly be said to be aseptic operations. 

Disinfection of mucous membranes is much 
more difficult than skin disinfection, and complete 
asepsis is impossible. The more powerful antisep- 
tics irritate the mucous membrane, and therefore 
induce conditions which favor the multiplication of 
those germs which escape destruction. Our prin- 
cipal resource, therefore, in the disinfection of the 
vaginal canal, must be by thorough cleansing with 
soap and water and the use of the milder and less 
irritating antiseptic solutions. 

Fortunately the vagina, in the healthy state, is 
not ordinarily the habitat of the pyogenic organisms. 

In 1887 Doderlein investigated the vaginal se- 
cretions and found pyogenic bacteria present in 
4 ^/g per cent, of the cases examined. He has been 
followed by many other investigators, who have 
had varying results. One class — including Gonner, 
Kronig, Williams, and Menge — have had almost 
negative results in regard to pyogenic organisms, 
while many others have found the staphylococci or 
streptococci present in from 4 to 27 per cent, of the 
cases examined. 

In view of the great discrepancy in the re- 
sults of the various investigators, Kronig made 
(126) 



VAGINAL OPERATIONS. 127 

the statement that the positive results obtained by 
most observers was due to fauUy methods of ob- 
taining the vaginal secretion, by which they them- 
selves introduced into the vagina the bacteria which 
they later found in their cultures. 

Kronig's view would seem to be correct, since 
so many careful bacteriologists have failed to find 
pyogenic organisms in a large number of examina- 
tions. 

Previous to this statement of Kronig, Williams, 
of Baltimore, had found pyogenic organisms in 
53 per cent, of his examinations. The vaginal 
secretion was obtained in these cases by introduc- 
ing a sterilized, cylindrical, glass speculum into the 
vagina, and taking the secretion from portions of 
the vaginal wall which apparently had not come in 
contact with the end of the speculum. Stimulated 
by the criticism of Kronig, he examined the vaginal 
secretion from 92 women, obtained by an apparatus 
invented by Menge, which obviates all danger of 
carrying bacteria into the vagina from the vulva. 
In this series of cases he was unable to cultivate 
streptococci or staphylococci, with the exception 
of 2 cases in which the staphylococcus epidermidis 
albus was present. 

The conclusion to be deduced from these in- 
vestigations is that in cases which have not been 
recently examined, and in which no disease of the 
cervix or uterine cavity exists, the vagina may be 
assumed to be free from pyogenic organisms. 

It has also been shown that the normal vaginal 
secretion is bactericidal, and destroys the strepto- 
coccus pyogenes in eleven hours. This teaches us 



128 SURGICAL ASEPSIS. 

that our principal efforts in disinfection must be di- 
rected toward the vulva and the surrounding re- 
gion, instead of the vagina. Unfortunately, the 
external organs of generation cannot be so easily 
or so certainly disinfected as can the hands. The 
skin in this situation is plentifully supplied with 
sebaceous glands, and, from the moisture usually 
present, this is a site of predilection for bacteria. 
Nor does the difficulty end when we have disin- 
fected the surface and appUed our dressing, but, from 
the necessary evacuation of the bladder and rectum, 
it is impossible to keep on a fixed dressing. 

For all these reasons operations upon the pel- 
vic viscera should, generally, be done by the ab- 
dominal route. Plastic operations upon the peri- 
neum, vagina, or cervix, and even a curettement are 
not so free from danger as is usually supposed. 

When an operation by the vaginal route is 
proposed, an examination should be made several 
days previous to the operation to determine J:he 
existence of any diseased process of the cervix or 
uterine cavity which would be apt to infect the 
vagina. Should any evidence of gonorrhoea be 
found, the operation should be delayed until re- 
covery has occurred. Should there be muco-pur- 
ulent discharge from the cervix, douches of potas- 
sium permanganate in the strength of 1 to 5000 
should be ordered twice a day. 

In the absence of any diseased condition of the 
vagina or cervix no douches are necessary. 

The intestinal canal, for several days previous 
to the operation, should be thoroughly cleared by 
a mild saline laxative each night, and the external 



VAGINAL OPERATIONS. 129 

genitals and the buttocks should receive a pro- 
longed bath with soap and water once a day. 

The night previous to the operation the pa- 
tient should be given an active saline. The hair 
should be shaved from the external genitals as far 
as the mons veneris, and the vulvar and anal re- 
gions thoroughly scrubbed with soap and water, 
and covered by a napkin saturated in 1 to 2000 
solution of mercuric chloride or a 1-per-cent. solu- 
tion of lysol. 

On the morning of the operation the patient 
should receive an enema of soap and water, at 
least three hours previous to the operation. If the 
enema is used later than this, its full action is apt 
to be delayed, the surgeon is embarrassed, and the 
result is endangered by the escape, during the op- 
eration, of faecal matter. 

After the patient is etherized and brought to 
the table, the feet and limbs should be protected 
by the sterilized Canton flannel socks. If these are 
not at hand, each limb may be wrapped in a sterile 
sheet. 

The surgeon or an assistant must now complete 
the sterilization of the field of operation so far as 
possible. For this the rubber gloves should be worn. 

First the buttocks and the anal region should 
be thoroughly scrubbed with soap and water and a 
gauze sponge. This sponge should be thrown away 
and the external genitals may then be scrubbed in 
the same manner, being careful to cleanse all furrows 
between the labia and about the clitoris. 

After this, the surface should be scrubbed for at 
least five minutes with a solution of bichloride of 





130 SURGICAL ASEPSIS. 

mercury 1 to 2000. Should there be any fear of an 
action of the bowels, the rectum may be packed by 
a strip of gauze. 

The nurse may now remove the gloves from 
the hands of the operator or assistant and he now 
proceeds to disinfect the vagina. This should con- 
sist, principally, in scrubbing with soap and water. 
Liquid antiseptic soap, with 10 per cent, of creolin 
added, may be used, or synol soap may take its place. 
The vagina should be distended by two fingers of 
the left hand, and the rugosities smoothed out. The 
scrubbing may be done by a gauze sponge held in 
a sponge holder, and should not be so hard as to 
injure the mucous membrane. Especial care should 
be bestowed on the cervical canal and the lower part 
of the vagina near the hymen. 

Following this cleansing the vagina should be 
irrigated with a 1-per-cent. solution of lysol or a solu- 
tion of permanganate of potassium in the strength 
of 1 to 5000. After the preparation of the vagina a 
protector made of two thicknesses of sterile gauze, 
one yard square, is spread between the thighs, cov- 
ering all the exposed parts and hanging well down 
over the buttocks on to the operating pad. The 
surgeon cuts an opening in this protector, corre- 
sponding to the vulva and only large enough to 
expose the field of operation. 

During the operation great care must be exer- 
cised lest the hands be allowed to come in contact 
with some part of the field which has not been com- 
pletely sterilized. 

Vaginal Hysterectomy. — Any contamination from 
the uterine discharges which are common in this 



VAGINAL OPERATIONS. 



131 



class of cases may be avoided by packing the uterine 
and cervical canal with gauze or by grasping the 
entire cervix with a broad, stout Museaux forceps. 
This completely closes the cervical canal and serves 
as a handle by which the uterus may be drawn down 
and held in any desired position. 

Only sterile water or sterile salt solution should 
be used for irrigation or sponging during the opera- 
tion. 

If clamps are used it will be necessary to pack 
the vagina with sterile or iodoform gauze, carrying 




Fig. 47. — Collins's Traction Forceps. 



the gauze well over the points of the clamps to pre- 
vent injury to the intestines. If ligatures only are 
used, the vaginal vault should be loosely packed with 
plain, sterile gauze and the vagina itself with plain 
or iodoform gauze. This gauze should be removed 
on the fourth or fifth day and followed in twenty- 
four hours by douches of sterile salt solution. In 
using this douche the vulva must first be thoroughly 
cleansed and then the vulvar orifice held apart by 
the fingers of the nurse and the tube introduced with- 
out touching the external genitals. A backward flow 
tube should be used and the douche bag should not 



132 



SURGICAL ASEPSIS. 



be elevated high enoug?i to give much force to the 
stream, or the newly formed adhesions may be 
broken up. 

Curettement. — After the diseased tissue has been 
removed by the curette, the interior of the uterus 
should be irrigated with sterile water. The intra- 
uterine tube has been sterilized with the rest of the 
instruments, and when it is to be used the surgeon 
will hold it in such a way that the nurse may attach 
to it the rubber piping of the douche bag, without 




Fig. 48.— Gauze Packer. 



permitting the tube to touch her hands or the pipni:; 
to touch the surgeon's hands. The intra-uterine 
douche should be used at a temperature of 112° to 
115° F., and should be continued until the fluid re- 
turns nearly clear. The cavity of the uterus should 
then be thoroughly dried by sterile absorbent cotton 
wound on a probe, or by gauze packing. After the 
uterus is dry its cavity should be swabbed w^ith a 
mixture of equal parts of Hquid carbolic acid, and 
tincture of iodine. This is applied by means of ab- 
sorbent cotton tightly wrapped on a uterine sound. 
The vagina and cervix should be protected from the 



VAGINAL OPERATIONS. 133 

escharotic action of the excess, which is pressed from 
the cotton during its introduction, by packing gauze 
about the vaginal vault. 

The uterine cavity is now packed with a strip of 
iodoform gauze and the vagina with sterile or iodo- 
form gauze. 

These tampons may be removed on the second 
day and followed by a daily douche as described for 
vaginal hysterectomy. 

Trachelorrhaphy. — Either chromicized catgut or 
silk-worm gut may be used for repair of the cervix. 
If a perineorrhaphy is done at the same time, catgut 
should be preferred for the cervix. The No. 2 
chromicized catgut will resist absorption for at least 
two or three weeks, and that is as long as any su- 
tures are required. 

In view of the investigations already mentioned 
it would seem safer to interdict the use of the douche 
after repair of the cervix for at least a week. The 
vulva may be washed with some mild antiseptic so- 
lution once or twice a day. 

Perineorrhaphy. — The repair of the perineum 
should cause as much anxiety as any simple abdom- 
inal operation. 

It is true that infection is not usually so serious 
in its consequences as when it occurs after laparot- 
omy, but the surgeon has it almost certainly in his 
power to avoid infection in the latter instance, while 
in the former, from the situation of the wound, much 
must be trusted to the competency and faithfulness 
of the nurse and something to unavoidable contami- 
nation during the convalescence. 

Should infection occur it is almost sure to nullify 



134 SURGICAL ASEPSIb. 

the effects of the operation, and may even lead to a 
fatal termination. Such a case has occurred in the 
practice of the author, and numerous other cases 
have been reported. 

If during the introduction of the stitches it is 
necessary to introduce the finger into the rectum, it 
should be covered by a rubber finger cot. After the 
finger is withdrawn, the cot should be removed by 
the nurse and the hand immersed in bichloride solu- 
tion for several minutes before the operation pro- 
ceeds. 

After the operation is completed the vagina 
should be washed out with sterile water and the peri- 
neum irrigated or sponged with the same solution. 
After it is dried with a gauze sponge, the line of 
sutures should be dusted with aristol, and a sterile 
vulvar pad, made of gauze and cotton, may be held 
in place by a T-bandage. 

The urine should not be voided, but the patient 
should be catheterized for at least a week. When 
the catheter is used the vulva and perineum should 
be protected by a sterile gauze pad, and the finger 
should be placed over the outer end of the catheter 
as it is withdrawn. 

The bowels should be moved on the second day, 
and every day thereafter, by a mild laxative or 
enema. 

Great care must be exercised by the nurse to 
avoid infection from the faecal matter. After each 
movement the patient should be cleansed as much as 
possible by directing a stream of antiseptic solution 
from above downward. The cleansing should then 
be completed by sponging with the same solution, 



VAGINAL OPERATIONS. 135 

washing away from the perineum, and on no account 
touching the wound surface. 

The sutures should remain until the wound is 
firmly united : usually ten or twelve days. The pa- 
tient should remain in bed for three weeks. 



CHAPTER XV. 

ARMAMENTARIUM OF THE SURGEON, 



The surgeon who frequently operates away 
from home will find it convenient to have a stock 
of gauze sponges, dressings, and other necessaries 
always prepared and ready to be packed in a trans- 




Fig. 49. — Washable Instrument Roll. 



portation valise at a moment's notice. The valise 
should be of large size and should always be sup- 
plied with the articles that are generally used in 
any operation. It should have loops on the side 
to hold at least six, 4-ounce, large-mouth bottles. 
These should contain potassium permanganate, ox- 
alic acid, tablets of bichloride of mercury, liquid 
soap, iodoform, celloidin, and common salt. 
(136) 



ARMAMENTARIUM OF THE SURGEON. 137 

The bag should also be stocked with ether, su- 
tures and ligatures, drainage tubes, nail brushes, a 
Kelly operating pad, fountain syringe, and two or 
three operating gowns. The dressings, sponges, 
and instruments may be selected according to the 
operation and packed into the same vaHse. The 
instruments may be conveniently carried in an in- 
strument roll made of Canton flannel or of brown 
duck. The instruments are held in the loops of a 
tape running lengthwise of the roll, the edges are 




Fig. 50. — Instrument Roll. 

turned inward over the ends of the instruments, and 
the roll is secured by a tape tied about it. 

It is well for the -surgeon to accustom himself 
.to use as few instruments as possible, and a great 
number are scarcely ever necessary. 

Almost any operation may be done with a 
scalpel, scissors, h:emostatic forceps, and needles. 
But special instruments simplify the work and are 
sometimes absolutely necessary. The ingenuity of 
the surgeon will often improvise good substitutes 
for many instruments when necessary. 



138 



SURGICAL ASEPSIS. 



Instrument lists for the usual operations should 
be kept and consulted when making the preparation, 
or the surgeon may sometimes find himself in the 
embarrassing situation of being ready to do an op- 
eration and some such essential article as a scalpel 
wanting. If some operation is to be done for which 
the surgeon has no list, he should go through the 
various steps of the operation mentally and write 
down each instrument required. 

Lists of instruments necessary for various op- 
erations are here given. Some of these instruments 
may be dispensed with or replaced by others. When 
an abdominal operation is performed it is necessary 
to have at hand some instruments which probably 
will not be required, but may be necessary from un- 
expected conditions. 

INSTRUMENTS FOR PERINEORRHAPHY. 



Eobb's leg holders. 

2 shepherd's crook tenacula. 

1 scalpel. 

2 pair dissecting forceps. 

1 pair scissors curved on flat. 
1 pair angular scissors. 



2 pair sponge forceps. 
1 pair needle forceps. 
6 large full curve needles. 
6 haemostatic forceps. 
1 Sims speculum, or perineal re- 
tractor. 



Fig. 51. — Shepherd's Crook Tenaculum. 




fflfflllfflPfflB 

Fig. 52. — Toothed Tissue Forceps. 



ARMAMENTARIUM OF THE SURGEON. 139 







Fig. 53.— Scalpels. 




Fig. 54. — Curved Scissors. 




iFig. 55. — Angular Scissors. 




Fig. 50. — Dudley's Hseraostatic Forceps. 



140 SURGICAL ASEPSIS. 

INSTRUMENTS FOR CURETTAGE. 



Robb's leg holders. 
Sims's speculum, or perineal re- 
tractor. 
Volsellum forceps. 
2 pair sponge forceps. 



1 pair uterine dressing forceps. 

1 strong steel dilator. 

2 curettes. 

Uterine douche tube. 
Uterine sound. 




Fig. 57. — Sims's Speculum, 




Fig. 58. — Skene's Tenaculum Forceps. 




Fiff. 59.— Goodell's Uterine Dilator. 



ARMAMENTARIUM OF THE SURGEON. 141 




Fig. 60. — Hanks's Conical "Uterine Dilator. 




Fig. 61. — Kocher's Curettes. 




Fig. G2. — Rinsing Curettes. 



Fig. 63.— Sims's Sharp Curette. 



• r -naiii- j8i'i.V.wei:a^:qM^.-^a;yg^^ ^^ ^ . .:: .°::iiili!Mi[IIIWIIIII!Mllllllllllllllllll!illllllllllllllllilii'wa^ 

Fig. 64. — Uterine Curette. 




si^2«ia^^£QQQQ^. 



Fig. 65.— Sims's Uterine Sound. 



142 



SURGICAL ASEPSIS. 




Fig. 66. — Leonard's Dilating Intra-uterine Douclie Tube. 



INSTRUMENTS FOR APPENDICECTOMY. 



1 scalpel. 

1 pair scissors. 

1 pair large retractors. 

1 pair small retractors. 

2 pair tissue forceps. 



2 pair sponge forceps. 
1 grooved director. 
1 pair needle forceps. 
6 needles. 
1 set Murphy buttons. 



6 pair haemostatic forceps. 




Fig. 67. — Straight Operating Scissors. 




Fig. 68. — Volkmann's Sharp Eetractor. 




Fig. 69.— 'Grooved Director. 



ARMAMENTARIUM OF THE SURGEON. 



143 



INSTRUMENTS FOR OVARIOTOMY. 



1 scalpel. 

1 pair straight scissors. 

1 pair curved scissors. 

1 grooved director. 

2 Kelly retractors. 

12 pair haemostatic forceps. 
2 pair tissue forceps. 



2 pair sponge forceps. 

2 hysterectomy clamps. 

1 Cleveland ligature carrier. 

6 needles. 

Aspirator. 

Cautery. 

Ovarian trocar. 




Fig. 70.— Kelly's Retractor. 




Fig. 71. — Tait's Haemostatic Forceps. 




Fig. 72, — Kocher's Hysterectomy Forceps 



144 



SURGICAL ASEPSIS. 




Kelly's Glass Ovarian Trocar. 



INSTRUMENTS FOR ABDOMINAL HYSTERECTOMY. 



2 scalpels. 

1 pair straight scissors. 

1 pair curved scissors. 

1 grooved director. 

2 retractors. 

12 haemostatic forceps. 
2 pair tissue forceps. 
2 pair sponge forceps. 



1 pair needle forceps. 
1 pair volsellum forceps. 
4 hysterectomy clamps. 
1 ligature carrier. 
1 uterine sound. 
1 silver catheter. 
6 needles. 
Cautery. 




Fig. 75. — Transfixion Ligature Carrier. 



ARMAMENTARIUM OF THE SURGEON. 



145 




Fig. 76. — Hysterectomy Forceps. 




Fig. 77. — Thermocautery. 



INSTRUMENTS FOR AMPUTATION. 



Tourniquet or Esmarch band- 
age. 
1 large scalpel. 
1 pair scissors. 
1 amputating knife, or catlin. 



1 pair bone forceps. 
1 pair needle forceps. 
Bone-saw, preferably 

lee's. 
V" dozen needles. 



6 to 12 haemostatic forceps. 

10 



Satter- 



146 



SURGICAL ASEPSIS. 



Fig. 78. — Amputating Knife. 



LIST OF ACCESSORIES FOR ANY OPERATION. 



Ether. 

Sterile sheets. 

Operating coats. 

Sterile towels. 

Gauze sponges. 

Dressings. 

Nail brushes. 

Liquid soap. 

Hydrarg. bichloride tablets. 



Oxalic acid crystals. 

Gutta-percha tissue. 

Drainage tubes. 

Sterile gauze. 

Absorbent cotton. 

Celloidin. 

Sutures and ligatures. 

Kelly's operating pad. 

Fountain syringe, or irrigator. 



Potassium permanganate crystals. 



CHAPTER XVI. 

INFECTED WOUNDS. 



Wounds may become infected by faulty tech- 
nique, by operating through infected tissues, or an 
accidental wound may become infected before it is 
seen by the surgeon. All infected wounds may 
lead to serious constitutional disturbances, but the 
changes in the wound itself will be principally re- 
garded here. The infective agent may be any of the 
pathogenic organisms, but usually the pus-producing 
bacteria are present. A wound which has become 
infected suppurates either in a part or in its entire 
extent, and heals by granulation. 

If a wound has been made by the surgeon 
through healthy tissues, it may be expected to heal 
without suppuration, and, if there are no indications 
of infection, the dressing need not be removed for 
ten or twelve days. Should the temperature remain 
above 101° F. for more than forty-eight hours, 
or if after falling it again rises after the third or 
fourth day, the dressing should be removed under 
rigid aseptic precautions and the wound inspected. 
Should there be redness or swelling about any of 
the sutures, the infection may be assumed to be a 
stitch abscess. The stitch should be removed and 
the wound pulled apart at that point. If it is earlier 
than the fourth or fifth day it is not probable that 
any pus has formed, but drainage should be pro- 

(U7) 



148 SURGICAL ASEPSIS. 

vided and the wound should be dressed daily there- 
after. 

Should the wound show no signs of inflamma- 
tion and if the symptoms are not urgent, the aseptic 
dressing may be replaced and the patient given a 
mild cathartic. After the action of this, should the 
temperature still remain above 101° F. or if chills 
or restlessness supervene, it may be assumed that 
there is deep seated infection in the wound, and it 
must be reopened to its bottom and drainage insti- 
tuted. An anaesthetic should be given and the wound 
reopened with the same precautions with which it 
was originally made, for, if no infection exists, im- 
measurable harm may have been done if the tech- 
nique has been faulty, and only slight injury if it has 
been perfect. Should a suppurating focus be found, 
the wound should be drained and closed in the man- 
ner already described for abscess-cavities. 

The dressing for this class of wounds is best 
made dry, either of sterile gauze or some of the 
medicated gauzes : iodoform, sublimated, or for- 
malin gauze. 

When incisions must be made through tissues 
which are hard and thickened from inflammatory 
action, provisional drainage should be used, for sup- 
puration may be expected. If only a limited area 
of inflammatory tissue is found and if it can be ex- 
cised, the wound may be safely closed. 

This class of wounds do best with a moist anti- 
septic dressing, covered by some impervious mate- 
rial to prevent evaporation. An excellent moist 
dressing is made by saturating a compress of sterile 
gauze of ten or twelve thicknesses in a solution of 



INFECTED WOUNDS. 149 

aluminum acetate. The standard solution of alumi- 
num acetate contains 8 per cent, of basic aluminum 
acetate, and this solution should be used in the pro- 
portion of 1 part to 15 parts of water. The excess 
of solution should be squeezed from the gauze, and 
this should be covered by dry cotton and then by 
oiled silk or gutta-percha tissue. 

If no suppuration has occurred in the wound at 
the end of three or four days, the drainage should 
be removed and the wound treated as an aseptic one. 

In those extensive areas of wide-spread infec- 
tion, as in cellulitis of the extremities or in pro- 
gressive purulent infiltration, the surgical treatment 
should be the same as for abscesses, only that the 
incisions should be multiple and should be two or 
three inches in length that the necrosed tissues may 
be curetted away and large tubular drains may be 
inserted. 

The drains should traverse the whole extent of 
the cavity. The tube may be carried into the first 
incision by means of a curved haemostatic forceps 
and a counter-opening made upon the point of the 
forceps in place where the drainage will be most 
effective. The cavity may be washed out with the 
aluminum acetate solution or by iodinized water, 
prepared by adding tincture of iodine to sterilized 
water in the proportion of 1 drachm to a quart of 
water. 

A copious moist dressing of solution of alumi- 
num acetate should be applied, and any newly af- 
fected area should be treated in the same manner. 

Palmar abscesses and suppurative tendo-vag- 
initis should be treated in the same energetic man- 



150 SURGICAL ASEPSIS. 

ner, for both are capable of causing wide-spread 
destruction of tissue if unchecked. 

Suppurative Osteomyelitis. — When suppurative in- 
flammation occurs in the medullary cavity of the 
bones, it is apt to cause extensive destruction of 
bone and intense septic infection, unless the pus 
finds an early exit through the compact layer of 
bone. As soon as a diagnosis can be made, the 
canal of the bone should be freely opened by chisel 
or gouge and the softened and diseased marrow re- 
moved with the curette. The cavity should then be 
as thoroughly disinfected as is possible. This course 
accomplishes in whole or in part the following re- 
sults : — 

1. It diminishes pain. 

2. It lessens destructive necrosis of the bone. 

3. It lessens the danger of fatal septicaemia. 

4. It enables the surgeon to remove much in- 
fected tissue, and thus expedites recovery. 

The preliminary preparation is made in the 
manner usual for other operations. After the dis- 
eased medullary tissue has been removed, the cavity 
should be washed out for five or ten minutes with 
a 1-per-cent. solution of lysol, and then mopped out 
with 95-per-cent. carbolic acid on a gauze pledget 
held in forceps and immediately followed by an ap- 
plication of alcohol. The stronger antiseptic solu- 
tions, like mercuric chloride or iodide, should not 
be used to irrigate the cavity, as from the porous 
nature of the bone-marrow a dangerous absorp- 
tion might occur. The same objection holds good 
against packing a large cavity with iodoform gauze, 
as is often advised. Either plain sterile gauze 



INFECTED WOUNDS. 151 

or formalin gauze should be used, and the wound 
covered by a copious absorbent dressing and placed 
on a splint. The wound should be dressed daily, 
and, if the temperature still remains high, the dry 
dressings may be changed to the dressings saturated 
with a 1-per-cent. solution of aluminum acetate. 

After the acute process has subsided, or in 
chronic cases in which the pus has found an exit for 
itself and is followed by necrosis of the bone, the 
sequestrum and all diseased medullary tissue should 






Fig. 79. — Decalcified Bone Chips. 

be removed, the cavity disinfected in the manner 
indicated, and then packed with decalcified bone 
chips as advised by Dr. Senn. The bone chips are 
strips of the compact tissue of bone from which the 
lime salts have been removed, and then the chips are 
preserved in an alcoholic solution of bichloride of 
mercury of a strength of 1 to 500. They resemble 
strips of cartilage, and are probably absorbed in the 
same manner as catgut. They serve to obliterate 
the cavity in the bone and act as a scaffolding for the 
formation of new bone. 



152 SURGICAL ASEPSIS. 

The strips should be soaked in sterile water for 
a short time to remove the solution with which they 
are saturated. They are then packed in the medul- 
lary cavity, level with the surface of the bone. If 
the periosteum has not been destroyed, it should be 
stitched with catgut and the overlying soft tissues 
closed without drainage, and the ordinary aseptic 
dressing should be applied. 

Dr. Senn has obtained unexpected results by 
this method, and the author has seen a case in which 
the removal of two-thirds of the medullary tissue of 
the femur was followed by primary union and no 
marked change in the contour of the limb. 

Should signs of infection occur, an anaesthetic 
should be given, the wound reopened, the bone chips 
removed, and the cavity cleansed as before described. 
The cavity may then be allowed to fill in by granula- 
tion, or a second attempt at implantation of bone 
chips may be made after suppuration has ceased. 

Accidental Wounds are always infected. Even if 
they have escaped infection from the washing and 
temporary dressing done by the patient or his 
friends, the object which inflicts the injury is a car- 
rier of bacteria, and the skin is always inhabited by 
them. 

While it has been shown that strong antiseptics 
have an injurious effect upon injured tissues, yet the 
damage wdiich may be caused by suppuration is so 
much greater, that the wound should be thoroughly 
treated by chemical disinfectants. 

The wound should first be covered by some anti- 
septic gauze, or a towel saturated in bichloride solu- 
tion, and the surface about the wound should be 



INFECTED WOUNDS. 153 

thoroughly scrubbed with soap and water and bi- 
chloride of mercury solution of the strength of 1 to 
1000. This disinfected surface should then be cov- 
ered by sterile or bichloride towels and the wound 
itself disinfected. If the wound is an incised one 
and does not communicate with any cavity of the 
body, it may probably be disinfected so that union 
by first intention may be secured. 

The wound should be thoroughly cleansed of all 
particles of dirt, or foreign matter, by forceps and 
pledgets of cotton. It should then be irrigated for 
at least ten minutes with a solution of bichloride of 
mercury in the proportion of 1 to 2000. 

If there has been contamination of the wound 
from street or stable dirt, the disinfection should be 
doubly thorough, from the liability of tetanic infec- 
tion. In such a case the wound may be quickly 
sponged with 95-per-cent. carbolic acid, followed by 
alcohol. Most incised wounds, if seen by the sur- 
geon within a few hours from the receipt of the 
injury, may be closed without drainage, with a fair 
prospect of union. Interrupted silk-worm sutures 
may be used, and, if signs of infection develop, two 
or three stitches should be removed at the most 
dependent part of the wound, and the opening may 
be kept patent by loosely packing with a strip of 
iodoform gauze. Instead of completely closing the 
wound, two or three provisional sutures may be left 
untied, and a gauze or rubber drain inserted. If no 
pus has formed after four or five days, the drain mav 
be removed and the sutures tied. Sterile dressings, 
towels, and sponges are not always available for use 
in accident surgery, and they are not necessary, as 



154 SURGICAL ASEPSIS. 

the treatment must be antiseptic, and not aseptic. If 
a sterile dressing may be had, the wound may be 
dusted with aristol and dressed with gauze and cot- 
ton. Instead of this, the wound may be covered 
with a number of thicknesses of iodoform or for- 
malin gauze and this by unsterilized absorbent cot- 
ton. The wound need not be inspected for three or 
four days, and, if no suppuration has taken place, it 
may remain undisturbed for two days more. If sup- 
puration has not occurred by this time the wound 
will heal by primary union. 

Contused Wounds are almost certain to suppurate, 
as they must heal by granulation. They should be 
trimmed of all hanging shreds of skin or muscular 
tissue, should be cleansed of dirt in the manner 
described for incised wounds, and, if small, may be 
disinfected by bichloride solution. If the wound 
surface is very extensive it is safer to substitute a 
1-per-cent. lysol solution for the bichloride, as absorp- 
tion of the drug may cause constitutional symptoms. 
The same remark may apply to dressing the wound 
with iodoform, either in powder or iodoform gauze. 
After the wound is disinfected as thoroughly as is 
possible, all parts that may be closed by sutures 
should be drawn together and supported by adhesive 
strips which pass over antiseptic gauze placed next 
to the wound. The wound may be dressed by dust- 
ing with aristol, and covering with some antiseptic 
gauze, preferably formalin gauze. The wound need 
not be dressed for three or four days, and daily there- 
after. Should there be marked inflammatory action 
and profuse suppuration, the dry dressing may be 
changed for continuous irrigation with a 1-per-cent. 



INFECTED WOUNDS. 155 

solution of aluminum acetate. This may be carried 
out by siphonage of the solution from a large vessel 
placed above the bed, the solution being conducted 
into a vessel beside the bed, by a piece of rubber 
cloth or Kelly pad placed beneath the part irrigated. 

Accidental wounds communicating with the 
cavities of the body are usually either stab or gun- 
shot wounds. 

Wounds of the chest, while always dangerous, 
are not necessarily fatal, unless large blood-vessels 
are injured. Better results may be expected from 
simply dressing a penetrating wound of the chest 
than by operative procedures. The external surface 
should be prepared in the usual manner, and an anti- 
septic dressing applied. 

Penetrating wounds of the abdomen give en- 
tirely different conditions than do those of the chest. 
If the course of the wound indicates injury to the 
abdominal contents, the abdomen should be opened 
regardless of the condition of the patient, unless he 
is moribund. Should the abdominal contents have 
escaped injury, the exploration should add no great 
danger, while, if injury has been inflicted, a fatal 
result is inevitable unless it can be averted by the 
art of the surgeon. If an injury of this nature is 
seen by a physician who is not prepared to open the 
abdomen, his efforts should be confined to cleansing 
the parts about the wound in the usual manner, and 
the application of an antiseptic dressing, until a sur- 
geon can be called. 

The earlier the abdomen is opened, the better 
will be the chance of recovery, and cases are usually 
fatal unless the operation is done within six or eight 



156 SURGICAL ASEPSIS. 

hours after receipt of the injury. Yet it is possible 
for recovery to follow operation after twenty-four 
hours. The author has seen recovery follow a gun- 
shot wound of the abdomen, in which the operation 
was performed twenty-four hours after the injury. 
The patient was accidentally shot through the abdo- 
men with a rifle ball. The wound of entrance was 
about two inches to the right, and an inch above, 
the umbilicus, and the point of exit was an inch 
above the brim of the pelvis, and three inches to the 
right of the spine. The wounds had been simply 
washed with bichloride solution and covered with 
bichloride gauze. 

A mass of omentum, about two inches long, 
protruded from the wound of entrance. From the 
course of the bullet it seemed almost certain that the 
intestinal tract must have been injured. The abdo- 
men was disinfected by the usual method, the pro- 
truding omentum was drawn out still farther, hgated, 
and excised, and then the abdomen was opened. 
The abdominal cavity contained considerable blood, 
some liquid faecal matter, and a fleshy mass four and 
one-half inches long and one inch wide at its widest 
part, and tapering at each end. When this was re- 
moved it was found to be the lower margin of the 
liver, which had been completely severed by the 
bullet. 

The injury to the ascending colon was sutured 
with fine silk, the abdomen was cleansed by dry 
sponging, and no irrigation was used. The wound 
was closed without drainage, and the patient made 
a rapid recovery. 

The method which was pursued in this case is 



INFECTED WOUNDS. 157 

the one to be advised. Should it be impossible to 
remove all foreign particles, it would be better to 
use drainage. 

This case was treated in an humble farm-house 
near the Canadian frontier, and well illustrates the 
possibilities of operative work outside the hospital. 

Compound Fractures should always be treated 
with scrupulous regard for antiseptic details, and 
the care will be rewarded by the saving of many 
limbs and an occasional life which would otherwise 
be sacrificed. 

The wound should be covered by a piece of 
sterile or antiseptic gauze, while the entire limb is 
scrubbed with soap and water and then with bichlo- 
ride solution. 

The surface about the wound should be shaved 
and the entire limb enveloped in sterile or moist bi- 
chloride towels. 

An anaesthetic should now be given. The 
wound should be disinfected by prolonged irriga- 
tion with bichloride solution 1 to 2000, carrying the 
irrigating point well down into the wound. 

The protruding fragment and the wound should 
be scrupulously cleansed of any foreign matter by 
forceps and sponging. Should the wound be too 
small thoroughly to disinfect the deeper parts, it 
should be freely enlarged, as free drainage is essen- 
tial in these cases. All loose fragments of bone 
should be removed, and should the fracture be one 
which is difficult to retain in place, the ends of the 
bones should be united by silver wire. Drainage 
should be established by the use of gauze or rubber 
tubing, and an aseptic dressing applied. The tern- 



158 SURGICAL ASEPSIS. 

porary splint or other dressing may be applied over 
this. When it is advisable to use a plaster splint, 
the v^ound should be covered by a small dry dress- 
ing, quadrilateral in shape, and covered by a piece 
of oiled silk which is wide enough nearly to encircle 
the limb and is twelve or fourteen inches long. Over 
this the plaster dressing is applied, and, before it is 
completely hardened, afenestrum is cut out over the 
wound, large enough so that the dressing may be 
changed. 

The oiled silk should now be cut through and 
reflected back over the four edges of the fenestrum. 
This prevents the moisture of the dressings from 
soiling and softening the plaster. The wound should 
now be treated by the general principles of wound 
treatment. 



CHAPTER XVII. 

MINOR ASEPTIC PROCEDURES. 



Catheterization. — The use of the catheter is usu- 
ally necessary after abdominal or plastic operations. 
Extreme care must be exercised lest the bladder 
become infected by its use, and it should be dis- 
pensed with at the earliest possible time. 

The secretion of urine is usually diminished after 
a surgical operation, and the catheter need not be 
used oftener than once in eight or twelve hours. 




Fig. 80. — Glass Female Catheter. 



For females, a glass catheter is best, and should 
be immediately cleansed after each use, and should 
be boiled for five minutes just before using again. 
Soft rubber catheters may be boiled for five minutes, 
although they are somewhat injured by this treat- 
ment. Instead of boiling they may be kept, when 
not in use, in some antiseptic solution. This solu- 
tion may be 5-per-cent. carbolic acid, bichloride of 
mercury 1 to 2000, formalin from 5 to 10 per cent., 
or 1-per-cent. lysol. The catheter should be re- 
moved from the antiseptic solution a few moments 

(150) 



160 SURGICAL ASEPSIS. 

before using and dropped into a basin of sterile water 
to remove the antiseptic. 

For office use a very convenient and efficient 
method of steriHzing rubber catheters is by means 
of formaldehyde gas in an apparatus made especially 
for this purpose. The catheters remain in the ap- 
paratus until required for use, and thus kept in an 
aseptic condition. This method has been considered 
the only reliable one for the sterilization of elastic 
web catheters, but Katzenstein has shown that we 
can depend only on a surface sterilization by this 
method, and that any germs which are enveloped in 
masses of mucus in the lumen of the catheter are 
not reached. It may therefore be said that no 
method except sterilization by heat is perfectly satis- 
factory for any kind of catheter. 

In the sterilization of elastic web catheters dis- 
infection by antiseptic solutions is of little value, 
since the germicidal fluid, if sufficiently strong to 
penetrate to and effectually kill all bacteria, will also 
serve to disintegrate or destroy the catheter coating. 
Boiling water softens and destroys the coating of 
these catheters, and so nearly all careful surgeons 
have discarded this useful variety of instrument as 
being incapable of perfect sterilization unless per- 
fectly new. 

There have recently been two methods discov- 
ered by which elastic web catheters may be boiled 
many times without injury, and asepsis is thus ren- 
dered absolute. The first method was discovered by 
Herman, who found that elastic web catheters and 
bougies could be boiled without injury in a satu- 
rated solution of ammonium sulphate. A little later 



MINOR ASEPTIC PROCEDURES. 161 

Claudius, of Copenhagen, announced that they can 
be boiled for long periods without injury in a con- 
centrated solution of common salt, of the strength 
of 1 drachm to the ounce. 

These methods have been tested by Drs. Cotton 
and Cabot, of Boston, and by the author, and they 
can be relied on for the sterilization of this form of 
catheter without injury to it. 

Catheterization upon the lemale may be per- 
formed in the following manner : The labia are sepa- 
rated by the thumb and forefinger of the left hand, 
while the whole vulva is cleansed by pledgets of 
sterilized cotton, held in dressing forceps and satu- 
rated with a solution of bichloride of mercury 1 to 
5000. The catheter should now be taken from the 
receptacle in which it has been boiled, without touch- 
ing its vesical end, and gently introduced. Before 
it is withdrawn the outer end should be covered by 
the finger to prevent dribbling of the urine over the 
vulva. No lubricant need be used for the female 
catheter. 

For the male, a silver catheter is preferable for 
the surgeon's use, as it may be repeatedly boiled 
without injury, and if properly introduced it causes 
less irritation to the mucous membrane than does 
the rubber one, on account of its smoother surface. 
If the catheter must be left for the patient or an un- 
trained attendant to use, the soft rubber or elastic 
web instrument is safer than one which is rigid. 

Catheters with a stylet are not to be recom- 
mended for the use of either the surgeon or the pa- 
tient. Whenever it is impossible to pass an elastic 

web catheter, a metallic one should be used. 

11 



162 SURGICAL ASEPSIS. 

Of all kinds of catheters, only those with a solid 
end beyond the eye should be purchased. Masses 
of dirt and mucus are apt to accumulate in this 
pocket and render asepsis impossible. 

A Lubricant is necessary for the male catheter. 
Vaselin or sweet oil may be very easily sterihzed by 
boiling for five minutes just before using. A prepa- 
ration called lubrichondrin is an excellent lubricant, 
which, being free from fats, is readily removed by 
simple washing. It is preserved in an aseptic state 
in collapsible tubes, and the portion remaining in 
the tube is not infected when a part is used. A 50- 




Fig. 81.— Male Catheter. 

per-cent. solution of boroglyceride is mildly anti- 
septic, and is not irritant to the mucous membrane. 

If the soft rubber catheter has been kept in a 
1-per-cent. lysol solution it may be sufficiently lubri- 
cated by this solution. 

The distended and diseased bladder which is 
common with prostatic disease has little • power to 
resist germs which may be introduced during cath- 
eterization. The method here described may seem 
too exacting to be carried out at each catheteriza- 
tion for any long period of time, but its strict observ- 
ance is the best safeguard against chill following 
catheterization, urethral fever, cystitis, pyelitis, and 



MINOR ASEPTIC PROCEDURES. 163 

possible infection of the kidney. The passing of a 
catheter in this condition carries as much responsi- 
bility for its aseptic performance as does a major 
operation. After everything is in readiness to pass 
the catheter, the penis should be disinfected with 
soap and water and bichloride solution, and then 
surrounded by a sterile or bichloride towel. Should 
there be any urethral discharge, this should be thor- 
oughly washed out with a solution of potassium per- 
manganate, 1 to 5000, or a 1-per-cent. lysol solution. 
This washing may be done with a small glass nozzle 
attached to the piping of a fountain syringe. The 
urethral orifice should be compressed about the tube 
until the canal is completely filled, and then the fluid 
should be allowed to escape. This irrigation should 
continue for at least five minutes. 

The hands of the surgeon are now disinfected, 
the catheter is taken from the receptacle in which 
it has been boiled or otherwise disinfected, and after 
being lubricated is passed into the bladder with as 
little force as possible. If all these precautions are 
used, catheterization chill and urethral fever, which 
are merely signs of infection, will be extremely rare. 

A patient, who always suffered from chill and 
fever from catheterization with ordinary cleanliness, 
was examined thoroughly for stone in the bladder 
by this method without any such disturbance, al- 
though the examination occupied nearly half an hour 
and several instruments were employed. 

It is sometimes necessary, after operations upon 
the urethra or bladder, to employ drainage of the 
bladder by a catheter fastened in the urethra for sev- 
eral days. This may be accompHshed by tying a 



164 SURGICAL ASEPSIS. 

piece of silk around the catheter and fastening these 
to strips of adhesive plaster passed about the penis. 
Instead of this an elastic catheter holder may be 
used. 

To prevent infection from following up the 
lumen of the catheter to the bladder, the catheter 
should be coupled to a piece of rubber tubing long 
enough to reach a basin or urinal placed beside the 
bed and partially filled with some antiseptic solution. 

If a graduated glass urinal is used, the amount 
of urinary secretion may be accurately measured and 
noted from time to time. 

The siphon action may be started in this appa- 




Fig. 82. — Elastic Catheter Holder. 

ratus by simply stripping the rubber tubing in a 
direction toward the receptacle. 

Care must be taken, especially after suprapubic 
cystotomy, that the catheter or tubing does not be- 
come occluded by masses of mucus. The nurse 
should be instructed to measure and record, every 
hour, the amount of urinary secretion, and, when- 
ever this stops, the tubing should be disconnected 
from the catheter and suction by means of a small 
glass syringe should be employed. If the mucus is 
not dislodged by this manoeuvre, a small quantity of 
sterile water may be forced through the catheter and 
thus drive the mass back into the bladder. 



MINOR ASEPTIC PROCEDURES. 165 

Bladder Washing is a procedure often necessary 
in the treatment of cystitis, especially of the chronic 
form. It is usually effected by irrigating through a 
catheter, coupled with a fountain syringe or other 
irrigating apparatus. The same aseptic rules should 
be observed as in simple catheterization. 

The coupling between the irrigator and catheter 
may be a simple glass or metallic tip, one end of 
which fits the piping of the irrigating apparatus, and 
the other end tapered to fit the catheter. If a special 
tip is not at hand, the glass portion of a medicine 




Fig. 83. — Wigmore's Attachment for Bladder Washing. 

dropper may be used. After all air has been ex- 
pelled from the piping by allowing some of the fluid 
to flow through it, the tip is inserted into the end of 
the catheter and a small amount of fluid may be 
allowed to flow into the bladder. Not more than 
six or eight ounces should be introduced at one time, 
and the flow should be shut off as soon as any feel- 
ing of distension occurs. The tip should now be 
removed from the catheter and the fluid allowed to 
flow out. The irrigation may then be repeated until 
the fluid returns clear. 

Instead of using the plain tip, one of the con- 



166 



SURGICAL ASEPSIS. 



nections made especially for this purpose may be 
used, and is more convenient. By its use the fluid 
may be allowed alternately to enter the bladder and 
to flow out without disconnecting the irrigating pipe 
from the catheter. These connections are of several 
patterns, the best known of which is the Wigmore 
attachment. This is a Y-shaped tube, of which the 
straight arm forms a connection between the irri- 




Fig, 84. — Fountain Syringe, Catheter, and Two-Way Stop-cock 
Prepared for Washing the Bladder. 



gating apparatus and catheter, while the branch is 
the outflow from the bladder. A sHding stop in the 
main arm controls the inflow and the outflow. 

A two-way hard rubber stop-cock may also be 
used, and the inflow and outflow may be controlled 
by simply turning the cock. 

One of the simplest connections is by means of 
a soft rubber T-pipe. This is simply a piece of rub- 



MINOR ASEPTIC PROCEDURES. 167 

ber tubing of T-shape with fittings for insertion both 
into the irrigating pipe and catheter. During the 
fining of the bladder the lower or dependent portion 
of the T may be closed by a stop-cock, clamp, or by 
the fingers. The bladder may be evacuated by clos- 
ing the tubing connected with the reservoir and 
opening the escape pipe. 

The irrigating fluid will vary with the diseased 
condition of the bladder and with the views of the 
physician. No doubt, much of the benefit to be de- 
rived from bladder washing results from mechanical 
removal of the accumulated bacteria and the mucus 




Fig. 85.— Soft Rubber T-pipe. 

which may act as a culture medium for them. For 
this purpose, sterile normal salt solution may be rec- 
ommended, and in many cases this alone can be used 
on account of the intolerance to any irritating anti- 
septics. It must be remembered that most condi- 
tions for which bladder irrigation would be advised 
are accompanied by considerable denudation of the 
mucous membrane, and absorption of poisonous 
antiseptics must be considered. 

In case of an acute cystitis resulting from gon- 
orrhoeal infection, the preliminary use of normal salt 
solution, followed, after the acute symptoms have 



168 SURGICAL ASEPSIS. 

subsided, by a solution of permanganate of potash, 
1 to 10,000, will give good results. 

In cases of chronic cystitis accompanying pro- 
static enlargement the residual urine should be drawn 
ofif with the catheter, once or twice a day, and the 
bladder irrigated with normal salt solution. It is 
doubtful if any germs can be destroyed by any anti- 
septic solution which will be tolerated by the bladder 
except those which are free upon the surface of the 
mucous membrane, and these can be removed by the 
mechanical washing wath the salt solution. Should 
it be decided to use some antiseptic solution, it 
should be potassium permanganate 1 to 10,000, or 
boric acid in saturated solution. 

Lydston's preference as an antiseptic irrigation 
is the following: — 

IJ Acidi carbolici, 2 ounces. 
Sodii biboratis, 4 ounces. 
Sodii salicylatis, 2 ounces. 
Glyeeiini, 1 pint. 
M. Sig. : Use one-half ounce to each pint of warm water, 
and add as much boric acid as the solution will dissolve. 

In these prostatic cases great care must be used 
that the bladder be not ruptured by too much dis- 
tension with the fluid. 

Exploratory Puncture is often necessary as a diag- 
nostic measure, and is often followed by aspiration 
at the same sitting. Thorough aseptic precautions 
should be used in the preparation of the surface 
through which the puncture is to be made, and the 
aspirating needle should be sterilized by boiling. 
After the instrument is withdrawn the puncture 
should be sealed by sterile gauze and celloidin. 



MINOR ASEPTIC PROCEDURES. 169 

Hypodermic Injections are so commonly used, 
and are so rarely followed by abscess or marked in- 
flammation, that very little precaution is used. Yet 
abscesses occur sufficiently often, and when they do 
occur they cast such reproach upon the operator that 
ordinary rules of aseptic work should always be used. 

Not only do abscesses sometimes follow hypo- 
dermic injections, but the germs of syphilis may be 




Fig. 86. — Potain's Aspirator, 

carried from one patient to another by the hypo- 
dermic needle. 

For the proper use of the hypodermic syringe, 
the skin of the patient should be disinfected over a 
small area, and the needle should be sterilized by 
boiling or passing through the flame. The barrel of 
the syringe should be occasionally filled with bichlo- 
ride solution and after half an hour should be rinsed 
with sterile water. If a metal syringe with a solid 
metal plunger is used, the entire syringe may be 
boiled. 



170 SURGICAL ASEPSIS. 

The fluid to be injected is the most important 
item in the operation. Nearly all drugs for hypo- 
dermic use may now be had in tablet form, and are 
usually carried by the physician. It is only neces- 
sary to dissolve the tablet in sterile water to have a 
sterile solution. A few minims of water may be 
placed in a teaspoon with the tablet and the water 
boiled by holding the spoon over a lamp. Should 
it be necessary to keep a stock solution on hand, the 
development of bacteria in the solution may be pre- 
vented by adding '^ / ^ of 1 per cent, of carbolic or 
salicylic acid. 

It is sometimes desirable to use some tincture 
or extract hypodermically instead of one of the alka- 
loids of the drug. Especially is this true of ergot. 
Fluid extract of ergot may be used in this manner, 
but it is quite irritating because of the acids which 
it contains. Parke, Davis & Co. prepare a fluid ex- 
tract of ergot especially for hypodermic use, which 
is free from irritating principles and is kept in an 
aseptic condition, by hermetically sealing it in glass 
tubes. 

Hypodermoclysis, or the introduction of a large 
amount of fluid into the cellular tissue, is accom- 
panied by much more danger of local infection and 
abscess than is the hypodermic injection, on account 
of the larger amount of fluid and consequently the 
larger number of bacteria which it may carry, and 
from the lessened resistance of the tissues from the 
pressure of the fluid. Extensive abscesses are not 
uncommon after a hasty and imperfect infusion into 
the cellular tissue. The most favorable site for the 
injection is under the breast, on account of the large 



MINOR ASEPTIC PROCEDURES. iTl 

amount of loose cellular tissue in that situation. 
From the small amount of cellular tissue and the 
firmness of the fascia, the limbs should not be se- 
lected for this purpose. 

Care must be taken that the salt solution to be 
used is absolutely sterile and is prepared according 
to the directions given in a former chapter. The irri- 
gating apparatus should also be thoroughly steril- 
ized as well as the hands of the surgeon and the sur- 
face about the proposed site of the puncture. 

The breast should be lifted bodily away from 
the chest wall as the needle is passed into the cellular 
tissue beneath it. 

Care must be taken that the solution is injected 
into the cellular tissue, and not into the mammary 
gland. 

The fluid will be forced into the tissue slowly, 
and not more than eight ounces should be injected 
at any one point. If this amount is introduced under 
one breast, the needle should then be introduced 
under the other. After the needle is withdrawn the 
puncture should be covered by sterile gauze or a 
celloidin dressing. 



CHAPTER XVIII. 

CONSTITUTIONAL DISTURBANCES DUE TO 
WOUNDS AND THEIR INFECTIONS. 



Whenever traumatism of any extent has been 
caused, the injury is followed by constitutional re- 
action. If this reaction is not the result of wound 
infection, the symptoms rapidly subside. 

SIMPLE TRAUMATIC FEVER. 

Simple traumatic fever is the systemic reaction 
which takes place when a wound is healing without 
the occurrence of infection. In all open wounds 
there is no certainty that a certain number of germs 
do not enter the wound, and this fever might be 
supposed to be due to a toxaemia sufficient to cause 
a rise in temperature, but not sufficient to cause in- 
flammation or suppuration. But this fever follows 
simple fractures and internal haemorrhages, without 
the communication with any open wound to furnish 
an atrium for infection. This proves that the process 
of metabolism going on at the site of injury causes 
the disturbance. Bergmann attributed it to the 
fibrin set free at the site of the wound, while Ewald, 
of Vienna, attributes it to the nucleins. 

Tillmans attributes it to the absorption of blood 

corpuscles and tissue cells which have been destroyed 

at the site of the wound, and considers that the use 

of chemical disinfectants augments traumatic fever. 

(172) 



CONSTITUTIONAL DISTURBANCES. 173 

A few hours after an aseptic wound is made the 
temperature gradually rises to 100° or 101° F. As 
the rise is gradual, this is not usually accompanied 
by a chill. The pulse rises to a corresponding degree 
with the temperature. 

The patient suffers very little except from 
thirst, and after twelve or twenty-four hours the tem- 
perature commences to recede and usually reaches 
normal by the morning of the third day, although 
slight increase may be noted at night for two or 
three days more. The diagnosis between traumatic 
fever and sepsis is principally to be made by the time 
of its onset. Unless a very gross error has been 
made in the aseptic technique, by which a sufficient 
number of bacteria enter the wound to cause an ex- 
treme degree of toxaemia, septic fever will not occur 
in less than four or five days, while traumatic fever 
will have run its course before that time. So a mod- 
erate degree of fever within the first four days need 
cause little anxiety, while any rise after that time 
should be viewed with suspicion unless its occurrence 
is well explained by some other condition. Trau- 
matic fever will be increased by blood-clot or any 
aseptic tissue which must be absorbed. Therefore 
the prophylactic treatment is complete hsemostasis 
and cleansing of the wound, and the avoidance of 
necrotic tissue in the wound from bruising, the use 
of antiseptics, or very hot water. The only treat- 
ment necessary is frequent cool sponging with alco- 
hol and water, and, if the symptoms are unusually 
severe, the administration of a saline laxative by the 
mouth or by enema. 



174 SURGICAL ASEPSIS. 

SAPR/EMIA. 

Saprsemia is that form of general systemic 
poisoning caused by putrefactive decomposition of 
blood-clot or necrosed tissue at the site of the 
wound. The toxaemia is caused by the entrance into 
the blood of chemical substances excreted by the 
bacteria, and not by the entrance into the circulation 
of the bacteria themselves. Putrefaction is not 
caused by the pyogenic germs, but by a class of 
bacteria called saprophytes. 

Very often there is a mixed infection, the sap- 
rophytes being accompanied by pyogenic bacteria, 
and then we have both saprsemia and septicaemia. 

The symptoms of sapraemia vary with the 
amount of the dead tissues to be acted on, by the 
peculiarities of the variety of saprophytes present, 
and by the rapidity of absorption into the circula- 
tion. There is a short period of malaise and head- 
ache three or four days after the operation, and this 
is quickly followed by a sharp rise in temperature 
and chill. This is often accompanied by vomiting, 
diarrhoea, and profuse perspiration. 

Should the amount of necrosed tissue be small, 
the saprophytes may exhaust the pabulum and re- 
covery ensue ; but it is possible for the system to be 
overpowered by the ptomaines of putrefaction so 
rapidly poured into the circulation, and a fatal result 
may occur in a few hours. 

The prophylaxis against sapraemia is careful 
asepsis and the limitation in the wound of any 
necrosed tissue or blood-clot which may become 
infected by putrefactive bacteria. When saprsemia 



CONSTITUTIONAL DISTURBANCES. 175 

has actually occurred, the proper treatment is ob- 
vious, and if immediately carried out is usually ef- 
fective. The putrefactive material must be imme- 
diately removed from the wound, and this followed 
by irrigation and drainage. 

SEPTIC INTOXICATION. 

Septic intoxication is of the same nature as 
saprsemia, except that the poisonous ptomaines are 
those elaborated by pus microbes, and not putre- 
factive saprophytes. It differs from bacteraemia by 
the fact that the toxaemia is caused by the absorption 
only of ptomaines, while in bacteraemia the poison- 
ing is caused by access of both ptomaines and bac- 
teria to the circulation. Septic intoxication usually 
results from an abscess, and the severity of the in- 
fection depends upon the absorptive power of the 
tissues in which the suppuration is located, and the 
amount of pressure within the abscess. 

An abscess with limiting walls within any of the 
cavities of the body may give very little elevation 
of temperature or other signs of septic absorption, 
and it is not uncommon to find a large accumulation 
of pus in the abdomen with no elevation of tempera- 
ture or chill to indicate its presence. 

The granulation tissue barrier which forms the 
walls of an abscess does not readily absorb the pto- 
maines, as was pointed out by Billroth, many years 
ago, but pressure within the abscess may force the 
toxins through the barrier or it may rupture it, thus 
opening up new spaces, giving a chill and rapid rise 
of temperature. 



176 SURGICAL ASEPSIS. 

The treatment of septic intoxication is by the 
immediate evacuation of the pus, ^Yashing the cav- 
ity with an antiseptic solution, and the estabhshment 
of effective drainage. If no large cavity of the body 
is infected by this procedure, the temperature and 
other symptoms rapidly subside after the pressure 
is removed. If this happy result follows the evacua- 
tion of the pus, a positive diagnosis of septic intox- 
ication, and not septicaemia, may be made. 

BACTER^EMIA. 

Bactersemia is that form of general infection 
in which pyogenic organisms are present and mul- 
tiply in the blood. This occurs both in septicaemia 
and pyaemia, and, as the two conditions often cannot 
be differentiated by clinical symptoms, the more 
general term of bactersemia may be employed. 

SEPTIC/EMIA. 

Septicaemia is that form of bacteraemia in which 
some variety of pyogenic bacteria are present in the 
blood in numbers which render it impossible for the 
leucocytes to destroy them. Pus microbes in Hm- 
ited numbers may be present in the blood without 
producing morbid symptoms. To cause septicaemia 
they must not only be present, but must multiply. 

The bacteria usually gain entrance to the blood 
from some primary focus of suppuration, and may 
enter the circulation by the lymphatic system or by 
direct invasion of the blood-vessel walls. Septi- 
caemia is usually a progressive sepsis, because the 



CONSTITUTIONAL DISTURBANCES. 177 

essential cause has passed beyond the reach of any 
local treatment. The intoxication in this form of 
sepsis is caused not only by ptomaines which are 
produced at the primary seat of infection, but also 
by ptomaines produced in the blood by the micro- 
organisms which it contains. 

While the bacteria usually gain entrance to the 
circulation from some primary suppurating focus, 
this is not always true, but general septic infection 
may result from wounds which heal without sup- 
puration. 

The symptoms of the disease vary with the 
rapidity with which the bacteria gain entrance to 
the circulation, the character of the bacteria, and 
the resisting power of the patient. 

If a large number of pyogenic organisms flood 
the peritoneal cavity by rupture of an appendical 
abscess, suppurating gall-bladder, or Fallopian tube, 
death may result within a few hours from the rapid 
absorption of the bacteria and their ptomaines. 

Septic infection from an accidental or operative 
woimd usually takes place within three or four days. 
The disease is usually ushered in by a chill, which is 
followed by febrile reaction and attended by extreme 
prostration. The patient often has a feeling of well- 
being, but is stupid and apathetic. The degree of 
fever may be moderate at the first and gradually in- 
crease to 103° or 104° F. This indicates progressive 
infection by the multiplication of bacteria in the 
blood. 

If the temperature at the onset is high it may 
be assumed that a part of the symptoms are due to 
the rapid absorption of ptomaines which were formed 

12 



1Y8 SURGICAL ASEPSIS. 

at the primary seat of infection. In other words, the 
septicceinia is compHcated by septic intoxication. 

The most grave cases of septicaemia are char- 
acterized by a low temperature, rapid pulse, profuse 
perspiration, diarrhoea, vomiting, and extreme pros- 
tration. DeHrium is usually, but not always, present. 

Should these symptoms develop, the disease is 
almost always fatal. A moderate temperature with 
a pulse not exceeding 120 per minute may justify 
a better prognosis, but all cases of bacteraemia are 
always extremely grave, and the less rapidly fatal 
cases of septicaemia are apt to become pyaemic. 

Acute septicaemia may result fatally in a few 
hours, and is usually fatal within a week from the 
beginning of the symptoms. 

The treatment of septicaemia must rest prin- 
cipally upon disinfection of the primary focus of 
suppuration, but this is scarcely ever effectual, as 
the bacteria have passed beyond the reach of the 
surgeon and are multiplying in the blood. Disin- 
fection of the primary seat of infection will, how- 
ever, cut off the supply of bacteria from that source, 
and should always be thoroughly carried out. 

All sutures must be removed and every por- 
tion of the wound rendered accessible to local treat- 
ment. All blood-clots or necrosed tissue should be 
removed and the wound irrigated with a 1 to 1000 
solution of bichloride of mercury. This may be fol- 
lowed, after the wound has been dried, by pure car- 
bolic acid, and this in turn by alcohol. Not more 
than 1 drachm of pure carboHc acid should be used 
on the surface of the wound. Honsell, of Tubingen, 
from a large number of experiments, places the 



CONSTITUTIONAL DISTURBANCES. 179 

maximum amount at 6 grammes, or 1^/2 drachms. 
Secondary disinfection of the peritoneal cavity is 
of Httle avail when symptoms of septicaemia follow 
an abdominal operation. It will seldom be under- 
taken except in those cases in which the symptoms 
denote a preponderance of saprsemia. In such a 
case the attempt to remove the infecting agent 
should always be made. 

A number of the sutures at the lower angle of 
the wound should be removed and the margins of 
the wound separated. The abdominal cavity should 
be flushed out with normal salt solution, care being 
taken that the wound is opened enough to secure a 
free exit for the fluid. 

The end of the rubber tube of the irrigator must 
be inserted into the deeper portions of the abdom- 
inal cavity, especially into the pelvic and the lumbar 
regions. After the abdominal cavity has become 
thoroughly cleansed in this manner a large glass 
drainage tube should be inserted and cared for in the 
manner already described. 

Should there be much peritoneal suppuration 
and should the condition of the patient warrant it, 
an anaesthetic should be given, the wound reopened 
throughout its entire extent, and drainage secured 
by an incision through Douglas's cul-de-sac or 
through the lumbar region. 

Should a localized suppuration be suspected, 
the wound should be reopened enough to admit the 
hnger, and all adhesions which may inclose collec- 
tions of pus should be broken down and the abscess- 
cavity should be washed and drained. 

The general treatment of septicaemia consists 



180 SURGICAL ASEPSIS. 

in the employment of strychnia and alcohol in large 
doses and alimentation by all the means at our com- 
mand. By these aids the leucocytes may be enabled 
to overcome the invading bacteria in a small per- 
centage of cases of septicaemia. 

PYAEMIA. 

Pyaemia is that form of bacteraemia in which 
the bacteria and their ptomaines are not only present 
in the blood, but also are carried by the blood-stream 
to widely separated organs and produce secondary 
suppurating points in those organs. It is septicaemia 
accompanied by metastatic abscesses. 

The name indicates that pus is present in the 
blood, but it is not necessary that pus corpuscles 
should be present. The pyogenic bacteria when 
concentrated at one point set up the suppurative 
process. 

The metastatic abscesses usually result from 
the breaking up of an infected thrombus. This 
thrombus forms near the site of the wound and as 
the coagulum breaks up the emboli are swept into 
the general circulation, and are arrested by the 
smaller blood vessels, and from the colonies of bac- 
teria which these emboli carry the secondary ab- 
scesses are produced. The infecting organism is 
usually the staphylococcus pyogenes aureus. 

The abscesses are most frequently found in the 
lungs, kidne3^s, liver, and spleen. The lymphatic 
glands are often enlarged, but seldom go on to sup- 
puration. 

The location and anatomical structures of the 



CONSTITUTIONAL DISTURBANCES. 181 

tissues m which the primary suppuration has oc- 
curred have much to do with the occurrence of 
pyaemia. As the metastatic abscesses which are the 
distinctive feature of the disease are caused by the 
impaction in blood-vessels, as emboli, of the pyog- 
enic organisms which are incorporated with frag- 
ments of blood-clot or other soHd particles, it foUows 
that the primary seat of infection must be at some 
point where conditions are favorable to the forma- 
tion of a thrombus. 

These conditions are present to a marked de- 
gree in the medullary tissue of bone and in the 
venous sinuses of the uterus. As might be supposed, 
a large proportion of the cases of pysemia follow 
acute osteomyelitis and puerperal infection. Minute 
thrombi form in small venous radicles at the point 
of primary infection. After a time these thrombi 
become softened by the action of the bacteria which 
have infected them and fragments are swept into the 
general circulation, bearing with thern the pus-pro- 
ducing germs. These emboli become arrested in the 
minute blood-vessels of distant organs and produce 
metastatic abscesses at the point of impaction. 

The Symptoms of pyaemia seldom develop before 
the ninth or tenth day after the operation or acci- 
dent which causes the wound. The onset of the 
disease is usually rather moderate unless the pyaemia 
is associated with or results from septicaemia. Tlie 
fever which accompanies pyaemia is always of an 
intermittent or remittent type, and is accompanied 
by frequently recurring chills which mark the devel- 
opment of new foci of infection. Excepting at the 
onset of the disease, the chills are not usually severe 



182 SURGICAL ASEPSIS. 

or prolonged, and are followed by fever with a tem- 
perature of 103° or 104° F. for several hours. As 
the fever subsides, perspiration becomes profuse. 
The pulse, which at the beginning of the disease is 
accelerated only during the febrile exacerbations, 
gradually increases in frequency and diminishes in 
strength until death ensues. 

The usual duration of the disease is from two 
to four weeks. Death rarely occurs during the first 
week of the disease, and it may be delayed for four 
or five weeks. Still more chronic cases with few 
secondary abscesses may survive for several months. 

The Treatment of pyaemia is almost entirely 
prophylactic: by the strict observance of aseptic 
rules during the operation and the secondary dis- 
infection of wounds which suppurate, before throm- 
bosis of the neighboring veins occurs. 

After the infected emboli gain access to the 
circulation they are beyond the reach of the sur- 
geon. In those chronic cases characterized by 
the presence of but few secondary abscesses, these 
should be opened and drained if their location can 
be determined. 

ERYSIPELAS. 

Erysipelas is an acute infectious inflammation 
of the skin, and in its pure and uncomplicated form 
this inflammation never causes suppuration or ex- 
tends deeper than the structures of the skin or mu- 
cous membrane. The essential cause of the disease 
is a streptococcus, from 3 to 4 micromillimeters in 
diameter, and is identical in its appearance with the 



CONSTITUTIONAL DISTURBANCES. 183 

Streptococcus pyogenes, except that it is slightly 
larger. This streptococcus was first discovered by 
Fehleisen in 1883 and was named by him the strep- 
tococciis erysipelatosis. With a pure culture of this 
streptococcus he produced erysipelas in animals, and 
successful inoculations were also made in man for 
therapeutic purposes. Of seven persons, the sub- 
jects of inoperable tumors, who were inoculated by 
Fehleisen, six developed typical erysipelas, while the 
seventh had passed through an attack of the disease 
only a few weeks previously and was probably pro- 
tected against a new attack. In some other instances 
a second inoculation failed after a successful one. 

In these inoculation experiments the microbes 
were found entirely in the lymphatic channels and 
in the connective tissue spaces, and when a pure 
culture was used suppuration never occurred. No 
streptococci can be found in the blood-vessels of the 
inflamed skin and they appear to be less numerous 
in close proximity to the blood-vessels. 

From the close resemblance of the streptococ- 
cus erysipelatosis to the streptococcus pyogenes, 
bacteriologists have been inclined to regard them 
as identical, while clinicians have been certain that 
erysipelas must be caused by a specific germ which, 
imaccompanied by other organisms, does not pro- 
duce suppuration. 

Since the experiments of Petruschky most bac- 
teriologists consider the identity of these varieties 
of streptococci to be proven. He obtained a pure 
culture of streptococci from the pus taken from the 
peritoneal cavity of a woman who had died from 
suppurative peritonitis secondary to puerperal para- 



184 SURGICAL ASEPSIS. 

metritis. By inoculations with this culture he pro- 
duced typical erysipelas in two women suffering 
from cancer. He assumes that inasmuch as he found 
streptococci present in the pus, and that those strep- 
tococci were capable of producing erysipelas, that 
the streptococcus pyogenes and streptococcus ery- 
sipelatosis are identical. This assumption is unwar- 
ranted unless it be further proved that every colony 
from a plate culture produced erysipelas, for, if 
mixed infection were present, in which both the 
streptococcus pyogenes and streptococcus of ery- 
sipelas were the active agents, the colonies from 
which he obtained his pure cultures might be the 
streptococcus erysipelatosis, while the suppuration 
might be due to the streptococcus pyogenes which 
could be cultivated from another colony. 

The close relationship of erysipelas and puer- 
peral infection has been recognized for a long time 
by obstetricians. An excellent illustration of this 
relationship was given in a hospital in which an 
epidemic of puerperal fever occurred. The puer- 
peral ward was converted into a skin clinic, in which 
erysipelas promptly appeared. 

For this reason it would appear to be possible 
that the septic peritonitis in Petruschky's case might 
be due to a mixed infection in which the strepto- 
coccus erysipelatosis was associated with some of 
the pyogenic cocci. 

There are most excellent reasons for the belief 
that the streptococcus pyogenes and that of ery- 
sipelas are not identical. As, during the past three 
or four years, there has been an increasing tendency 
to regard erysipelas as due to the streptococcus 



CONSTITUTIONAL DISTURBANCES. 185 

pyogenes, the subject will be considered at some 
length. 

The reasons for the belief in the non-identity 
of the streptococcus pyogenes and the streptococcus 
erysipelatosis are these : — 

1. Inoculation with the streptococcus obtained 
from cases of erysipelas produces erysipelas without 
suppuration, while inoculation with the streptococ- 
cus obtained from pus produces suppuration without 
dermatitis. Hajek undertook to show that the strep- 
tococcus of erysipelas is neither in form nor culture 
materially different from the streptococcus pyog- 
enes, but in his inoculation of fifty-one rabbits, 
either cutaneously or subcutaneously, with a pure 
culture of the streptococcus obtained from a case 
of erysipelas, the result in every instance was a 
superficial, migrating dermatitis which resembled 
to perfection erysipelas in the human subject, while 
similar injections with the streptococcus of pus pro- 
duced a more intense and deeply seated inflamma- 
tion, which in almost every instance terminated in 
suppuration. 

2. Abscesses which show the streptococcus 
pyogenes in large numbers are not accompanied by 
erysipelas. Were the streptococcus pyogenes ca- 
pable of producing erysipelas, the opening of such 
an abscess would almost certainly be followed by 
the disease. 

3. Erysipelas is a self-limited disease which 
usually runs its course in one or two weeks, and one 
attack appears to protect the patient from the dis- 
ease for a certain length of time. Infection by the 
streptococcus pyogenes shows no tendency to spon- 



186 SURGICAL ASEPSIS. 

taneous recovery or protection against subsequent 
infection. 

4. That cases of erysipelas accompanied by 
suppuration are cases of mixed infection seems prob- 
able from the tendency to metastatic suppuration in 
those cases. If the non-suppurative cases were due 
to the same organisms, metastasis would occur in 
these also. 

5. Microscopical examination of the diseased 
tissue shows a marked difference in the localization 
of the bacteria. According to Hajek and Fehleisen, 
the streptococci in cases of erysipelas are found only 
exceptionally in the immediate vicinity of blood- 
vessels, while, in streptococcic infection character- 
ized by pus-formation, the streptococci can always 
be seen arranged in radiate lines around the vessels, 
entering into the coats of the vessel, and often into 
its lumen. The streptococci in erysipelas are con- 
fined to the lymphatic vessels and connective tissue 
spaces, while in suppurative inflammation they ex- 
tend beyond these structures and invade different 
kinds of tissue. 

For these reasons, it seems probable that ery- 
sipelas is caused by a specific organism which is so 
nearly identical in its appearance, growth, and stain- 
ing properties with the streptococcus pyogenes that 
it cannot be differentiated by the microscope, but 
that it produces much different lesions in the tissues 
of the human subject than does the latter organism. 

Erysipelas in all its forms is essentially a wound 
infection. The cases of so-called idiopathic ery- 
sipelas develop from some slight infection atrium. 
The period of incubation recorded in cases which 



CONSTITUTIONAL DISTURBANCES. 187 

have been inoculated for therapeutic purposes ranges 
from fifteen to sixty-one hours. 

The disease usually has a sharp onset, accom- 
panied by a chill, and in a few hours the temperature 
rises to 103° or 104° F. or more. The fever is con- 
tinuous, with only slight variations in uncomplicated 
cases. Simultaneously with the appearance of gen- 
eral symptoms the skin in the immediate vicinity of 
the infection atrium shows evidence of superficial 
inflammation. From the point of infection the in- 
flammation spreads continuously by the reproduc- 
tion of the streptococci. The affected skin presents 
a characteristic rose or crimson color. This color 
disappears under pressure, but upon removal of the 
pressure no depression is left. The induration of the 
skin is most marked at the margin of the inflam- 
matory zone, and, according to Koch and Fehleisen, 
the streptococci are always more numerous in this 
margin than in other portions of the affected area. 

The infection has reached its height at the orig- 
inal point of infection at the end of one or two days, 
and the inflammation subsides here while it extends 
at the margins of the diseased area. This local sub- 
sidence of the inflammation seems to be due to the 
exhaustion of the pabulum necessary for the growth 
of the bacteria. 

The degree of swelling varies according to the 
intensity of the infection and the anatomical struct- 
ure of the part involved. If the infection is mild, 
and if the skin is tightly stretched over resisting 
parts, the swelling is much less than if the infection 
is intense and the affected parts are abundantly sup- 
plied with connective tissue. 



188 SURGICAL ASEPSIS. 

Often vesicles or bullae appear. The bullae are 
the result of the confluence of a large number of 
vesicles. The contents of these blisters are serous 
and contain large numbers of streptococci. Some- 
times the contents become purulent by secondary 
infection by pus microbes. 

The duration of an attack of erysipelas is vari- 
able, but a typical attack usually lasts from one to 
two weeks. From the somewhat definite course and 
the protection which one attack secures against a 
subsequent one, it seems reasonable to suppose that 
the streptococci may elaborate an antitoxin which 
finally destroys the germs, as is the case in diph- 
theria. When erysipelas appears in an operation 
wound, it usually occurs within two or three days 
after the operation or dressing at which infection has 
taken place. The skin around the wound seems 
firmer to the touch and presents the characteristic 
crimson color. If suppuration is present, the puru- 
lent discharge becomes diminished in quantity and 
more serous. 

In general, the prognosis of simple, uncompli- 
cated cases of erysipelas is good. Unless it exists as 
a complication of some extensive wound, it is fatal 
only in the aged, or by some complication, as sec- 
ondary infection by pus microbes or by metastatic 
abscesses. 

The course of the disease is very little influenced 
by treatment. The burning and smarting of the skin 
may be relieved to some extent by lead and opium 
wash or by an ointment of ichthyol and lanolin in a 
strength of 10 per cent. Such measures as injections 



CONSTITUTIONAL DISTURBANCES. 189 

of antiseptics at the margin of the disease or paint- 
ing with tincture of iodine have proved useless. 

Powell treats erysipelas with 95-per-cent. car- 
bolic acid and alcohol. With a mop of absorbent 
cotton he applies the carbolic acid to the skin, and as 
soon as it turns white he applies alcohol freely to 
arrest its action. The acid should be applied from 
half an inch to an inch beyond the margin of the 
disease. If the diseased surface is extensive, it should 
be treated in sections. I have never used this 
method, but it would seem improbable that the staph- 
ylococci imbedded in the skin could be destroyed 
by any means which would not be destructive to the 
skin also. 

Recently a number of cases have been treated 
by antistreptococcic serum, apparently with good 
results. This serum is prepared from a mixture of 
the streptococci from puerperal fever, erysipelas, and 
pseudodiphtheria, and is intended for use in all these 
conditions. If the streptococcus of erysipelas is dis- 
tinct from these other varieties, the disease should 
be treated with an antitoxin prepared from this alone 
and unassociated with organisms from other sources. 
At the present time such an antitoxin has not ap- 
peared. 

In the treatment of operation wounds compli- 
cated by erysipelas, in addition to the measures al- 
ready indicated free drainage from the wound must 
be secured if suppuration is present, and a moist 
antiseptic dressing of lysol or aluminum acetate 
should be applied. The medicinal treatment of ery- 
sipelas should be simply supporting. Large doses 
of tincture of chloride of iron are usually prescribed, 



190 SURGICAL ASEPSIS. 

but should not be used if it disturbs the digestion. 
Sedatives to control the delirium and nervous dis- 
turbance, v^ith supporting doses of quinia, strychnia, 
and alcohol, should be used. 

It is a self-limited disease, the course of which 
is unaffected by any measures at our command un- 
less it may be an antitoxic serum, which has not as 
yet been proved. 

TETANUS. 

Tetanus is a traumatic infectious disease, caused 
by the entrance, through some wound of the surface 
or gastro-intestinal tract, of tetanus bacilli into the 
tissues. 

These bacilli are especially found in stable ex- 
creta, and are common about stables, farm yards, 
highways, and in garden soil. They are more plenti- 
ful in warm climates, and in summer and autumn 
than at other seasons. They are distinctly anaerobic, 
or incapable of multiplying in the presence of air or 
oxygen, although the microbes may retain their vi- 
tality for four or five months when exposed to the 
air, and may multiply as soon as a nutrient medium 
and the exclusion of air is found. On account of 
these characteristics, the disease is most likely to 
develop in punctured wounds, especially of the hands 
or feet, as wounds of this nature are more exposed 
to the entrance of dirt from the stable, garden, or 
street. 

The disease is especially liable to result from 
slight injuries to the hands of children from toy pis- 
tols or fire crackers, and every Fourth of July cele- 
bration is followed by numerous cases of tetanus. 



CONSTITUTIONAL DISTURBANCES. 191 

The disease also frequently follows compound fract- 
ures which have been infected by street dust or 
stable dirt. It seldom occurs as the result of an 
operation wound, but may follow an abdominal op- 
eration, and I have known it to follow an operation 
for haemorrhoids by the ligature method. 

Within the past two years quite a number of 
cases of tetanus have been reported, following the 
use of diphtheria antitoxin and vaccination. Seven 
deaths followed the use of one lot of antitoxin in 
Naples, Italy, and twenty cases, with twelve deaths, 
recently occurred in St. Louis. The St. Louis anti- 
toxin was all taken from the same animal, and he 
showed signs of tetanus about five weeks after the 
antitoxin was drawn. 

In Camden, N. J., seven fatal cases of tetanus 
followed vaccination, and four occurred in Cincin- 
nati, Ohio, at about the same time. Whether the 
virus used was the carrier or whether the germs of 
tetanus accidentally gained access to the scarified 
area has been a disputed point. As stable excreta 
are the normal habitat of the bacillus of tetanus, it 
seems reasonable to suppose that the virus may have 
become contaminated either in the pustule or during 
its removal. 

From the investigation of the epidemic in 
Naples, it was decided that the serum was contami- 
nated after it was drawn. In the St. Louis epidemic 
it is uncertain whether the germs were present in 
the circulation of the horse at the time the serum 
was drawn or whether it became contaminated from 
faulty technique in its withdrawal. From the length 
of time that elapsed before the horse developed the 



192 SURGICAL ASEPSIS. 

disease it would seem probable that the latter was 
the case and that the animal was infected at the same 
time. 

It follows that only such serum and virus should 
be used as has been experimentally tested for the 
presence of tetanus bacilli before it is sent out from 
the laboratory. 

The Bacillus of Tetanus is a slender rod which 
presents no characteristic features unless spore-for- 
mation has occurred. At body temperature the ba- 
cilli develop spores within themselves, which give 
a characteristic shape, described as the drumstick 
form. This shape is caused by the round spore 
which develops at one end of the rod. 

The bacilli in which no spores have formed are 
destroyed by the ordinary means of steam steriliza- 
tion, but the spores are very resistant and require 
fractional sterilization for their destruction. 

The development of tetanus is rather retarded 
than favored by suppuration in the wound. The 
wound has usually healed promptly, but a minute 
abscess may be found at its bottom. 

The bacilli of tetanus have rarely been found 
in the blood or in tissues remote from the primary 
entrance of the germs. The symptoms seem to be 
due to toxins which are formed by the bacilli in the 
tissues near the infection atrium, and, after being 
taken into the circulation, they act on the central 
nervous system much as does strychnia. Kitasato, 
who has studied the disease artificially produced in 
animals, reports that the spasms first begin in the 
muscles nearest the site of inoculation. This shows 
that the toxins which are formed near that point act 



CONSTITUTIONAL DISTURBANCES. 193 

upon the terminal nerve-fibers before they gain ac- 
cess to the circulation in sufficient quantity to act 
on the central nervous system. 

Acute tetanus usually develops in about one 
week after the receipt of the injury, although the 
period of incubation is considerably influenced by 
the number of bacilli introduced, the presence of 
dirt or other foreign bodies in the vv^ound, and the 
character of the tissues involved. 

The first symptoms usually are stiffness of the 
muscles of the jaw, then of the back of the neck, and 
in a few hours all the muscles of the back are af- 
fected. At first there is only stiffness and some pain 
upon motion, but this is rapidly followed by violent 
spasm of the muscles of the body and lower extremi- 
ties. Owing to the spasm of the sphincters, volun- 
tary movements of the bowels and bladder are very 
difficult. 

The mind usually remains clear throughout the 
course of the disease, and the temperature is not 
usually much elevated, but near the close there may 
be hyperpyrexia. The pulse increases in rapidity 
steadily as the exhaustion from the convulsions in- 
creases. The disease usually results fatally within 
a week from its onset, and may do so within a few 
hours. The disease occasionally takes a more 
chronic and milder course. In these cases the symp- 
toms do not usually make their appearance until the 
third or fourth week, and recoveries are not unusual. 
The cases which have this favorable termination may 
be accompanied by severe spasms, but there are 
periods during which the patient experiences relief 
from the muscular contractions. These periods 

13 



194 SURGICAL ASEPSIS. 

gradually become longer and finally the contractions 
disappear. 

The prognosis in the acute form is exceedingly 
grave, while a fair percentage of the chronic cases 
end in recovery. 

Generally, the longer the period of incubation, 
the more probable is the recovery of the patient. 
The possible explanation of this fact may be that but 
a small number of bacilh enter the wound, and that 
during the time that the germs are multiplying to 
the extent that they can cause symptoms, the patient 
is becoming immunized to their action, in the same 
way that animals are immunized by successive inocu- 
lations with progressively increasing doses of the 
living cultures. 

Treatment. — The prophylaxis consists in strict 
attention to the details of asepsis, and the thorough 
disinfection of punctured wounds of the hands or 
feet, especially if they have come in contact with 
street dirt, garden soil, or stable dressing. 

If a wound has occurred under these circum- 
stances, it should be enlarged to a sufficient size for 
its thorough cleansing by water, and this should be 
followed by pure carbolic acid and alcohol. Free 
drainage by gauze should be established, as it is only 
in closed wounds that tetanus may be expected to 
develop. 

After the disease has developed, local disinfec- 
tion of the original wound is of the greatest service. 
It is in this immediate vicinity that a great part of 
the germs are located. The wound should be re- 
opened to its bottom, and, if possible, the tissues in 
its immediate vicinity should be excised. The wound 



CONSTITUTIONAL DISTURBANCES. 195 

should then have a prolonged irrigation with a solu- 
tion of bichloride of mercury or should be treated 
with carbolic acid and alcohol. 

Several cases have been reported in which an 
immediate improvement followed this plan of treat- 
ment, and Senn reported the remarkable recovery 
of a patient in whom tetanus followed an operation 
for acute osteomyelitis. Immediate improvement 
followed the secondary disinfection of the wound, 
and the patient finally recovered. 

Chloral Hydrate seems to be the most efficacious 
drug in the treatment of the disease. In very large 
doses it will relieve the muscular spasm, but it does 
not seem to lessen the mortality. Chloroform and 
morphia are the only other drugs which are of serv- 
ice, and these only palliate the symptoms. 

Serum-therapy. — The treatment of tetanus by 
the injection of the serum of animals rendered im- 
mune by repeated inoculation has been practiced to 
quite an extent during the past five or six years, but 
with no very marked success. 

The injection of the serum of an immunized 
animal will protect another animal from developing 
the disease if the injection is made prior to the in- 
fection. The serum can also modify the disease and 
prevent a fatal result if it is injected at the time of 
infection or very soon after. Its efficacy is in inverse 
ratio to the time which has elapsed after infection 
before the serum is used. If used only after the 
symptoms have fully manifested themselves, it seems 
to have little effect. 

Recently injection of the serum into the brain 
substance has been practiced, apparently with better 



196 SURGICAL ASEPSIS. 

results. The injection is made into one of the frontal 
lobes, through a small hole in the frontal bone made 
by a bone-drill. Such radical measures are advis- 
able, should further experience prove that the in- 
tracerebral injections are more efficacious than the 
subcutaneous or intravenous use. 

If the serum is used only after tetanic symptoms 
have appeared, relatively large doses will be required, 
and the amount required rapidly increases according 
to the length of time the disease has existed. Tak- 
ing Behring's serum as a standard, 100 cubic centi- 
meters of the serum should be injected during the 
first twenty-four hours in a well-developed case, and 
two or three times this amount would be required 
for a case in which the well-marked symptoms had 
existed for two or three days. 

At the present time the serum must be regarded 
principally as a protection against the disease, and, 
after it has developed, as an adjuvant to the other 
methods of treatment, of which disinfection of the 
primary seat of the disease is the most important. 



CHAPTER XIX. 

ASEPTIC MIDWIFERY. 



Every puerperal woman is a surgical patient, 
inasmuch as there is always a trauma at the placental 
site, and usually at the cervix or perineum also. 
Most of the pathological conditions following labor 
are due to infection of these wound surfaces during 
labor or subsequently. 

The mortality from puerperal sepsis has greatly 
diminished during the past decade, but it is not yet 
unknown to us. 

It has already become known to the laity that 
childbed fever is not due to ''taking cold," but is due 
to infection, and its occurrence casts reproach upon 
the physician or the nurse or both. 

For many reasons the country physician is often 
unable to conduct a perfectly aseptic labor. Often 
his first knowledge of the case is a hurried call into 
the country, where he may find the patient well ad- 
vanced in labor, possibly on an unclean bed, and at- 
tended by a nurse who knows nothing whatever of 
asepsis even if she does of cleanliness. 

The correction of this condition rests with the 
physician, who should always explain the dangers 
of such a course. But more difficult than the attain- 
ment of surgical cleanliness during the labor is the 
task of keeping the parturient canal free from germs 
during the convalescence. 

(197) 



198 SURGICAL ASEPSIS. 

Advice to the family regarding a nurse is often 
a delicate subject. Only exceptionally is this advice 
sought, and often some acquaintance or friend of the 
family who occasionally nurses obstetric cases has 
been engaged before the physician is consulted. It 
is even more necessary that the obstetric nurse 
should understand the principles of asepsis than that 
the surgical nurse should. After an abdominal sec- 
tion the surgeon may cover the wound by a dressing 
which excludes all germs, but this cannot be done 
with the puerperal patient, and much depends upon 
the conscientious after-care by the nurse. 

Upon proper occasions the physician should in- 
struct his patients in this respect, and should always 
endeavor to impress the most essential part of the 
aseptic technique upon whatever nurse may be forced 
upon him. 

But there are many physicians who are them- 
selves guilty of culpable neglect in respect to aseptic 
precautions. They would make much more elabo- 
rate preparation for a slight surgical operation, yet 
sepsis following the amputation of a limb would be 
much less serious than that following a delivery. 

When the physician is engaged to attend an 
obstetric case, he should attempt to have a reliable 
nurse employed also, and he should have the patient 
under observation for the last few months of preg- 
nancy. 

THE PATIENT'S OUTFIT. 

Some time previous to the expected time of 
confinement the physician should give the patient a 
list of the articles to be provided by her. These 



ASEPTIC MIDWIFERY. 199 

articles are to be used by the nurse before the arrival 
of the physician. 

They should be in readiness three or four weeks 
before the expected date of labor, and should be as 
follows : — 

1 dozen towels. 4 ounces lysol. 

1 new nail brush. 1 pint alcohol. 

4 ounces antiseptic or tr. green 25 tablets of mercuric chloride, 
soap. V2 pound of absorbent cotton. 

Safety pins of various sizes. 

An Obstetric Pad, to be placed under the patient's 
hips after confinement, is restful to her, and protects 
the bed from soiling by the lochia. It is made one 
yard square, by quilting a layer of ordinary cotton 
batting between two layers of cheese cloth. 

Sanitary, or Vulvar, Pads are made by covering 
with plain absorbent gauze a rectangular piece of 
absorbent cotton, ten inches long, three or four 
inches wide, and two inches thick. Two or three 
dozen of these pads should be made. If it is neces- 
sary to economize, these pads may be replaced by 
the usual linen or cotton napkins. 

Two Pieces of Eubber Sheeting are convenient for 
preparing the bed. These should be one yard wide 
and one and one-half to two yards in length. They 
may be of the cheap enameled cloth, although the 
rubber sheeting is more flexible and to be preferred 
on that account. If these are not provided, the bed 
may be protected by spreading several layers of 
newspapers between the other coverings. 

Abdominal Bandages are best made from very 
thin outing tiannel, and may be made in the same 



200 SURGICAL ASEPSIS. 

manner as the surgical binder. Four or six band- 
ages should be made. 

Three or four wash-basins and two toilet pitch- 
ers will be needed, as well as a slop jar. 

Beside the dozen tow^els mentioned as being 

put aside, an abundant supply of clean towels, sheets, 

night gowns, and undervests should be in readiness. 

.A Fountain Syringe should always be included 

in this list, and should be new or nearly so. 

THE PHYSICIAN'S OUTFIT. 

The physician's obstetric bag should be supplied 
with not only the articles which he will need in addi- 
tion to those included in the list given the patient, 
but he must be prepared for a case in which these 
articles have not been secured. 

The following is a good list of articles with 
which it may be stocked, but the list may be changed 
to suit the fancy and requirements of the physi- 
cian : — 

Silver or glass catheter. 1 rubber apron or gown. 

Obstetric forceps. Kelly pad. 

Straight scissors. Fountain syringe. 

Intra-uterine douche tube. Antiseptic soap or tr. green 

6 pair haemostatic forceps. soap. 

Ashton's or Peaslee's perineum Corrosive sublimate tablets. 

needle. Nail brushes. 

6 curved needles with large eye. Lysol. 

Needle forceps. 1 tube lubrichondrin. 

Catgut and silk-worm gut su- Va dozen sterile towels. 

tures. V2 dozen sterile vulvar pads. 

Bobbin thread or tape for the 1 dozen sterile gauze sponges. 

cord. V2 pound absorbent cotton. 

V2 dozen rubber finger cots. Chloroform. 

1 pair rubber gloves. Ether. 



ASEPTIC MIDWIFERY. 201 

Such an outfit as the above includes everything 
which would probably be needed in an ordinary 
labor, and the list may be reduced by one-half and 
still contain the articles usually required. 

PREPARATION OF THE ROOM. 

At the onset of labor the nurse should notify 
the physician and then prepare the room and the 
patient. 

The lying-in room should be large, airy, and 
sunny. All superfluous furniture and draperies 
should be removed. The necessary furnishings are 




Fig. 87. — Ashton's Perineal Needle. 

a bed, one or two tables, a wash-stand, and necessary 
chairs. 

The Bed should be prepared in such a way that 
the soiled clothing beneath the patient may be easily 
removed after the labor is terminated, leaving the 
patient on a dry bed. 

The mattress should be covered by one of the 
pieces of rubber cloth, and this by a folded draw 
sheet. These should be pinned to the edges of the 
mattress, and over them should be a sheet. This 
makes the bed as it is to be occupied by the patient 
after delivery. 

The temporary coverings, to be removed after 
labor is completed, consist of a second rubber sheet 
covered by a folded white sheet. These are also 



202 SURGICAL ASEPSIS. 

securely pinned to the sides of the mattress. Before 
the conclusion of the first stage of labor a Kelly pad 
should be placed under the patient's hips, and the 
apron so placed as to convey the fluids into a slop jar 
placed beside the bed. 




Fig. 88.— Kelly's Cervical Needle. 

At the earliest indications of labor the nurse 
should sterilize some water to be set away to cool, 
and should also sterilize the dozen towels in two 
packages, and one dozen of the vulvar pads, each 
of which is wrapped separately in cotton cloth. If 
no sterilizer can be had, these may be sterilized in 
a clean cooker or wash-boiler in the manner pre- 
viously described. 

PREPARATION OF THE PATIENT. 

The first step in the preparation of the patient 
should be the administration of a copious enema of 

TRUAX GREENE-tO, 



^ 



Fig. 89. — Palmer's Cervical Needle. 

soap and water. She should then be given a full 
bath, either by sponging or in a bath-tub if the pains 
are not too active. After this she is attired in fresh 




OQ 



c 

G 

C 
o 



11. 



I 



ASEPTIC MIDWIFERY. 203 

clothing, and, if comfortable enough to be up, she 
may have a loose wrapper or bath robe over the 
night gown. 

After the arrival of the physician, but before an 
examination is made, the external genitals should be 
disinfected. The hair on the labia should be cHpped 
off with scissors, and then the external surface of 
the labia, the perineum, and buttocks should be 
washed with soap and water and bichloride solution 
in a strength of 1 to 2000. After this the vulva 
should be carefully cleansed with 1 to 4000 bichlo- 
ride solution or a 1-per-cent. lysol solution. 

The Ante-partum Douche has been the subject of 
much discussion in years past, but it has been aban- 
doned by nearly all obstetricians, unless the patient 
shows infection of the vagina or cervix. From the 
investigations of Doderlein, Kronig, and Williams, 
which have been mentioned in the chapter on vaginal 
operations, it seems to be proved that the vagina 
and cervix do not usually contain pyogenic cocci, 
unless as a result of gonorrhoeal infection. As in- 
fection must come from without, it is unnecessary to 
disinfect the vagina unless there are signs of gonor- 
rhoea, and any antiseptics capable of destroying pus- 
germs are injurious to the epithelial layer of the 
vaginal mucous membrane. 

Our efforts at securing asepsis should consist 
in a thorough disinfection of the examining hand, 
and of the parts with which it will come in contact 
before entering the vagina. After the disinfection 
of the external genitals the vulva should be covered 
with a sterile i)ad, or, in the absence of this, by a 
napkin soaked in a 1 to 1000 solution of mercuric 



204 SURGICAL ASEPSIS. 

chloride wrung as dry as possible. Should an evacua- 
tion of the bowels occur after this, the disinfection 
should be repeated. 

CONDUCT OF LABOR. 

Soon after the arrival of the physician he will 
make an examination to determine the position 
and to detect any abnormalities of the foetus or 
parturient canal. After this initial examination they 
should be very infrequent, and in a normal case no 
other examination is necessary during the first stage. 
Many obstetricians determine the position of the 
foetus by abdominal palpation, and abandon the 
vaginal examinations. The position of the foetus 
is only one of the many things which a vaginal ex- 
amination reveals, and if done in a proper manner 
there should be no danger of infecting the patient. 

After the nurse has prepared the patient in the 
manner already described, the physician should ster- 
ilize his hands in the manner described for a surgical 
operation. Unless he has been in attendance on 
some septic case, the Fiirbringer method, by means 
of soap and water and bichloride solution, is all that 
is necessary. 

Should he recently have seen any contagious or 
septic case, he should disinfect the hands by the po- 
tassium permanganate and oxalic acid method. A 
still better plan in such a case is to wear the sterile 
rubber gloves. The rubber gloves interfere to some 
extent with the tactile sense, but they should always 
be worn if the physician has recently examined a 
case of puerperal septicaemia or is in attendance on 



ASEPTIC MIDWIFERY. 205 

a case of erysipelas or phlegmonous inflammation. 
Usually no lubricant is needed in making the exami- 
nation, but, should it be desired, the hands may be 
immersed in a 2-per-cent. lysol solution, which is 
both antiseptic and lubricant, or freshly steriHzed 
vaselin or lubrichondrin may be used. 

After the physician's hands have been sterilized 
the nurse removes the sterile vulvar pad, and raises 
the sheet which covers the patient in such a way that 
the physician can see the vulva, taking care that the 
clothing shall not come in contact with his hands. 
The physician, with the fingers of the left hand, sepa- 
rates the labia as widely as possible, while the ex- 
amining finger is passed into the vagina without 
coming into contact with the external genitals. The 
left hand may now be used over the abdomen for 
bimanual palpation, but it should not be forgotten 
that it is no longer aseptic. 

This same method of hand disinfection should 
precede every examination during the labor. 

At the commencement of the second stage the 
nurse should prepare a large toilet pitcher full of 
bichloride solution 1 to 2000, and two quarts of a 
2-per-cent. lysol solution, using sterile water at a 
temperature of 110° to 115° F. The few necessary 
instruments — as the catheter, scissors, and douche 
tube — should be sterilized by boiling at the same 
time. 

On one table may be placed the sterile instru- 
ments, sponges, towels, and vulvar dressings, while 
on another may be placed the solutions. 

The Kelly pad, which has been placed under 
the hips of the patient before the conclusion of the 



206 SURGICAL ASEPSIS. 

first stage, is covered by a large sterile towel or one 
which has been wrung out of bichloride solution. 

During the second stage the examinations must 
be more frequently made, and, if the physician avoids 
handling unsterile objects, the thorough scrubbing 
with soap and water may be omitted before each ex- 
amination, but the hands should always be immersed 
in the bichloride solution for two or three minutes. 
To avoid contamination from contact of the hands 
with his own clothing it is well for the physician to 
wear a sterile gown, which he may carry in his ob- 
stetric bag, having been previously sterilized. 

As soon as the head has descended sufficiently 
to distend the perineum, the attention of the physi- 
cian should be constant, for the protection of this 
structure, and the vulva and adjacent parts should 
be frequently cleansed by means of a sponge wet in 
the bichloride or lysol solution. 

Should any of the contents of the rectum be 
expelled during the pains, the nurse must imme- 
diately cleanse the surface, by sponging away from 
the vulva toward the sacrum. Should the physi- 
cian's hands come in contact with the faecal matter, 
they must be scrupulously disinfected before pro- 
ceeding further. Should the towel under the hips 
of the patient become soiled, it must be immediately 
replaced by a fresh one. Should the physician con- 
sider it necessary to introduce the finger into the 
rectum for the protection of the perineum, it should 
be covered by a rubber finger cot. 

After the delivery of the child the placenta 
should be removed by expression, except in case of 
alarming haemorrhage or the rare condition in which 



ASEPTIC MIDWIFERY. 20T 

the attachment of the placenta to the uterus is so 
firm that it cannot be removed by the Crede method. 
In these instances it may be necessary to pass the 
hand into the uterus, but this must never be done 
except in the greatest emergency and under the most 
rigid aseptic details. 

The nurse should provide some receptacle for 
the placenta. A shallow tray or basin is the best. 
It may be covered by a bichloride towel and the tray 
may be held closely against the left buttock of the 
patient, so as to receive the placenta as well as the 
gush of blood and clots which follow its expulsion. 

The vulva and surrounding parts should now be 
cleansed by the physician, as his hands alone are 
aseptic. This cleansing may be done by sponging 
with some antiseptic fluid or by irrigation with the 
fountain syringe. The sponging should first be con- 
fined to the vulva, and last the surrounding tissues. 
After this is completed a sterile vulvar pad should be 
applied, the Kelly pad and the temporary coverings 
of the bed should be removed, and the obstetric pad 
placed under the hips of the patient. 

The binder may now be applied, and, if by any 
chance the patient's clothing has become soiled, they 
should be changed. 

EMERGENCY CASES. 

The physician will often be called under such 
circumstances that the method here advised cannot 
be fully carried out, but the cardinal principle — that 
an examination should never be made until the 
hands of the physician and the genitals of the pa- 



208 SURGICAL ASEPSIS. 

tient have been disinfected — may always be insisted 
upon. Should the delivery be so nearly completed 
that this cannot be done, the only assistance the pa- 
tient Avill require will be the support of the perineum, 
and no vaginal examination is necessary. 

If sterile towels and napkins for the patient can- 
not be obtained, a temporary vulvar dressing which 
has been wrung from bichloride solution may be 
used until the vulvar pads or napkins may be steril- 
ized by steam. 

The old method of saturating the napkin in 
alcohol had some merit as a disinfectant, and not by 
preventing the patient from taking cold, as was for- 
merly believed. 

INSTRUMENTAL LABORS. 

Whenever it is necessary to employ instruments 
in any way during the labor, surgical asepsis must 
be strictly followed. If this is done the danger of 
infection is not increased by instrumental interfer- 
ence, and an intelligently conducted forceps delivery 
is less likely to be followed by sepsis than is a pro- 
longed labor, during which the tissues have been 
injured by the long continued pressure of the foetal 
head, and are rendered less resistant to the bacteria 
which may be carried into the vagina by the repeated 
examinations, despite the utmost care of the ac- 
coucheur. 

Usually the patient should be anaesthetized 
when any instrumental interference is necessary, and 
should be placed in the dorsal position. This posi- 
tion may be maintained best by the gynaecological 



ASEPTIC MIDWIFERY. 209 

Operating strap or by an assistant holding each limb. 
Whatever instruments will be required are sterilized 
in the usual manner by boiling, and the pan or other 
receptacle in which they are sterilized may be used 
as an instrument tray. 

While the physician is steriHzing his hands by 
one of the reliable methods, the nurse may again 
thoroughly scrub the vulva and surrounding parts 
with soap and water followed by bichloride solution. 
The field should be kept in an aseptic condition by 
sterile or bichloride towels, so arranged that only 
the vulva is exposed. 

The physician should now thoroughly disinfect 
the vaginal outlet by sponging or irrigation with a 
1-per-cent. lysol solution. After this is done the 
catheter is passed and the physician again immerses 
his hands in bichloride solution before commencing 
the operation. 

Should any lubricant be needed for the hands 
or instruments, the lysol solution will be sufficient, 
and is an antiseptic. 

The same vigilance against contamination of 
the hands by any unsterilized object should be ob- 
served as during any surgical operation. 

REPAIR OF LACERATIONS. 

Lacerations of the Perineum. — At the conclusion 
of labor the perineum should be inspected, and, if 
laceration to any degree has occurred, it should be 
repaired. The instruments required will be a peri- 
neum needle, three or four haemostatic forceps, 
scissors, and a curved surgeon's needle with an eye 



210 SURGICAL ASEPSIS. 

which will carry catgut. The patient should be 
placed in the lithotom}'^ position, and, after the va- 
gina has been cleansed of blood and clots by a 
douche of sterile water, the upper portion of the 
vagina should be packed with sterile gauze to keep 
the field of operation free from blood. If sterile 
water and gauze are not to be had, the douche may 
be a 1-per-cent. lysol solution, and 5-per-cent. iodo- 
form gauze may take the place of sterile gauze. 

The sutures on the skin surface of the perineum 
should be of silk-worm gut and must be passed 
deeply into the tissues. The stitches in the median 
line are passed close to the rectum, but must not 
penetrate any of its coats. To avoid this it is nec- 
essary in deep lacerations to pass the index finger 
of the left hand into the rectum, and it should be 
protected by a rubber finger cot, to be removed as 
soon as this portion of the operation is completed, 
and the hands must be again disinfected before the 
operation is continued. 

After the silk-worm sutures have been intro- 
duced, but before they are tied, the laceration of the 
vaginal mucous membrane extending up the poste- 
rior wall of the vagina should be closed by a con- 
tinuous suture of catgut, and the skin sutures are 
then tied. 

After the removal of the vaginal pack and the 
cleansing of the perineum of blood, the surface is 
dusted with aristol and covered by a sterile vulvar 
dressing. 

The catheter should be used for four or five 
days, care being taken not to allow the urine in the 
catheter to contaminate the wound as the instru- 



ASEPTIC MIDWIFERY. 211 

ment is withdrawn. Care must also be taken that 
the wound is not infected by faecal matter, and 
the cleansing should always be from the perineum 
toward the sacrum. 

Lacerations of the Cervix are usually only discov- 
ered after convalescence, although immediate repair 
has some advocates. On account of the rapid in- 
volution of the uterus after confinement, the sutures 
rapidly become slack, and do not hold the margins 
of the wound in apposition for more than twenty- 
four or forty-eight hours. On this account, and also 
because any operation upon the upper portion of 
the vaginal canal or the uterus after labor increases 
the danger of infection, the immediate repair of the 
cervix is not to be advised unless it is necessary 
to check severe haemorrhage from the laceration. 
Whenever excessive haemorrhage which cannot be 
attributed to imperfect contraction of the uterus 
occurs, a laceration involving the cervical blood- 
vessels should be suspected and sought for. Should 
it be found upon examination, the haemorrhage 
should be controlled by closing the laceration with 
catgut sutures drawn very tightly. The first suture 
should be so passed through the tissues of the cervix 
as to encircle the bleeding point, and the remainder 
of the sutures passed in the usual manner for cervical 
lacerations. The same aseptic precautions are used 
as in repair of the perineum. 

THE DOUCHE. 

From the difference in the practice of physi- 
cians regarding the use of the douche, both before 



212 SURGICAL ASEPSIS. 

and after confinement, it is well to consider the 
matter to some length, that its exact value and 
dangers may be more clearly defined, and a more 
uniform practice employed. 

First it may be stated that puerperal infection 
is always caused by infection through the vaginal 
canal, and is uninfluenced by atmospheric condi- 
tions or the diet of the patient. The principal ques- 
tion regarding the use of the douche is whether 
puerperal sepsis is ever caused by auto-infection by 
means of the bacteria present in the vaginal canal. 

While good authorities were about evenly di- 
vided on this question for the decade following the 
first investigations of Conner in 1887, it has been 
shown during the last five years that the diverse re- 
sults of the earlier investigators were due to errors 
in the technique in securing the vaginal secretions 
for the examination, and at the present time it is 
well settled that the vaginal secretions are free from 
germs which can produce septicaemia, unless the 
woman has gonorrhoea or has been recently exam- 
ined. 

This absence of germs is due to the bactericidal 
power of the vaginal secretions, which was proved 
by Kronig to be destructive to staphylococci and 
streptococci in from six to twenty hours. He there- 
fore concluded that the vagina may be assumed to 
be free from germs if the woman has been untouched 
for a period of two or three days. Doderlein veri- 
fied Kronig's experiments, and he attributes the 
germicidal power of the vaginal secretion to the 
acidity of the secretion. 

Dr. J. Whitbridge Williams has conducted a 



ASEPTIC MIDWIFERY. 213 

large number of experiments in the lying-in ward 
of the Johns Hopkins Hospital, the results of which 
he gave in detail in a paper read before the American 
Gynaecological Society in May, 1898. 

In this series of experiments he has conclu- 
sively shown that the vaginal secretion of pregnant 
women does not contain the usual pyogenic cocci, 
and that the results of investigators who have found 
these organisms in a considerable percentage of 
their examinations were due to errors in the method 
of securing the vaginal secretion, by which the bac- 
teria, which they afterward found, were carried into 
the vagina by the instruments used. 

The present status of vaginal bacteriology can- 
not be better told than by Dr. Williams's conclu- 
sions : — 

1. As the vagina does not contain pyogenic 
cocci, auto-infection by them is impossible ; and 
when they are found in the puerperal uterus they 
have been introduced from without. 

2. The gonococcus is occasionally found in the 
vaginal secretion, and during the puerperium may 
extend from the cervix into the uterus and tubes. 

3. It is possible, but not yet demonstrated, in 
very rare instances, that the vagina may contain bac- 
teria, which may give rise to saprgemia and putre- 
factive endometritis by auto-infection. 

4. Death from puerperal infection is always due 
to infection from without, and is usually due to neg- 
lect of aseptic precautions on the part of the phv- 
sician or nurse. 

Assuming that these conclusions are correct, it 



214 SURGICAL ASEPSIS. 

may be seen that the antepartum douche is entirely 
unnecessary, and that during its use bacteria may be 
carried into the vaginal canal by the tube. Kronig 
asserts that the douche favors sepsis in this manner 
and also by lessening the antiseptic power of the 
vaginal secretion. 

It is also plain that if the vaginal canal is free 
from germs at the commencement of labor, and if 
the examinations have been conducted with aseptic 
precautions, that the post-partum douche is entirely 
unnecessary. 

Should there be any doubt regarding the per- 
fection of the technique, a douche of 1-per-cent. lysol 
solution should be used after the completion of 
labor. This should be the last used during the puer- 
perium unless septic symptoms develop. Should the 
vaginal discharge be offensive after four or five days, 
the douche may be used as a sanitary measure. Usu-. 
ally this odor is due to the decomposition of the dis- 
charges after they have reached the vaginal outlet, 
and frequent cleansing of the vulva by some mild 
antiseptic will be sufhcient to prevent its occurrence. 

The intra-uterine douche may be necessary in 
those septic cases which arise from infection of por- 
tions of placenta, blood-clots, or retained lochia from 
a retroflexion sufficient to obstruct the outflow from 
the uterus. 

Whenever the intra-uterine douche is required, 
it should be used by the physician. It should be 
preceded by a careful cleansing of the external geni- 
tals with soap and water and bichloride solution 1 
to 2000, and a vaginal douche of 1-per-cent. solution 
of lysol, or potassium permanganate solution 1 to 



ASEPTIC MIDWIFERY. 215 

5000. Very little can be dene in the way of disin- 
fecting the uterine tissue by the douche, but the solu- 
tion washes away the accumulated debris and bac- 
teria, and so prevents the absorption of ptomaines. 
It is doubtful if any antiseptic solution in the strength 
in which it can be used in the uterine cavity has any 
advantage over sterile water or sterile salt solution. 

The douche bag to be used for the intra-uterine 
douche should be steriHzed by boiling unless it is a 
new one, in which case it may be filled with 1 to 
1000 bichloride solution for not less than half an 
hour. The cut off should be slipped down to the 
end of the piping and closed so that the piping may 
be disinfected as well as the bag itself. 

The tube to be used should have an outflow to 
insure a free escape for the irrigating fluid. 

After these preparations have been made and 
a douche pan placed under the hips of the patient 
the physician disinfects his hands in the usual man- 
ner, takes the intra-uterine tube from the pan in 
which it has been boiled, and holds it in such a man- 
ner that the nurse may connect it with the piping 
of the douche bag without allowing her hands to 
come in contact with the tube. 

One or two fingers of the right hand should then 
be passed into the vagina to locate the external os, 
and under their guidance the tube is passed into the 
uterus. 

AFTER=CARE OF THE PATIENT. 

The patient should be cautioned against remov- 
ing the vulvar pad or touching the genitals with 
her hands. Every time it is necessary for the nurse 



216 SURGICAL ASEPSIS. 

to change the vulvar pad or otherwise touch the 
patient the hands should be sterilized. The vulvar 
dressings should be sterilized by steam for the first 
five or six days, after which freshly laundered nap- 
kins may be used. 

Sterilization of the vulvar dressings by baking 
in an oven is not sufificient. It is as easy to sterilize 
them by steam in an improvised sterilizer, and steam 
is much more effective than dry heat. 

The pads should be changed as frequently as 
they become saturated, and the vulva should be 
bathed frequently by a 1-per-cent. solution of lysol 
or 1 to 5000 bichloride solution. 

PUERPERAL INFECTION. 

The essential condition in any case of puerperal 
fever is wound infection. The atrium may be in 
lacerations of the perineum, vagina, or cervix, or — 
as is more often the case — at the placental site. 

The form of infection may be either saprsemic 
or septic. 

Saprsemia occurs as a result of the decomposi- 
tion of portions of placental tissue or blood-clots 
which have become infected by saprophytes. These 
saprophytes are non-pyogenic and do not enter the 
blood, but the poisoning is due to toxins absorbed 
through the placental wound. 

Septic Infection is caused by the entrance to the 
circulation, through some w^ound surface of the geni- 
tal tract, of bacteria or their toxins. If only the 
toxins are absorbed, the infection is a septic intoxi- 



ASEPTIC MIDWIFERY. 217 

cation, while if the germs also enter the blood the 
condition may be designated as bactercemia. 

The necessity of the differentiation of the vari- 
ous forms of infection will be apparent when the 
treatment is discussed. 

Generally speaking, the germs which cause sep- 
tic infection are of the pyogenic group, although 
infection may occur from the streptococcus erysipe- 
latosis, the bacillus of diphtheria, or by the specific, 
but as yet undetermined, organism of scarlet fever. 

Septic Intoxication is caused by the absorption 
by the blood of the toxins elaborated at the original 
point of infection, which is usually the placental site. 
Should the local lesion be surrounded by a zone of 
granulation tissue, the patient may be protected from 
the entrance into the blood of the bacteria. Infec- 
tion may extend to the peritoneal cavity, setting up 
a peritonitis or septicaemia, either through the me- 
dium of the blood-vessels or lymphatics. 

Bactercrmia is caused by the entrance into the 
circulation of bacteria as well as the toxins which 
are formed at the original source of infection. If 
the bacteria are taken into the blood directly from 
the local lesion, septicaemia is produced, but if the 
blood infection comes through an infected thrombus, 
which in its disintegration throws into the circula- 
tion fragments of the clot which are infected by bac- 
teria, pyaemia is the result. 

Often septicaemia and pycemia are associated. 
Ideal conditions for the development of septic 
thrombi in the uterine sinuses are present in the 
puerperal uterus. 



218 SURGICAL ASEPSIS. 

DIAGNOSIS OF THE FORM OF INFECTION. 

While a diagnosis of the variety of infection is 
very desirable,, both on account of the prognosis and 
the treatment to be employed, it is often impossible 
to determine, and often there is a combination of 
the various forms, a sapr^mia furnishing an excel- 
lent culture field for the development of the pyog- 
enic bacteria, or a localized infection, which at first 
produces only a septic intoxication, runs into a bac- 
teremia. 

The practical value of the differentiation of the 
various forms of infection lies in the fact that sapre- 
mia and septic intoxication are amenable to local 
treatment, while in bactersemia the germs have 
passed beyond the reach of local measures, and no 
radical operation should be undertaken. 

Puerperal Sapraemia usually develops symptoms 
within three or four days of the date of confinement, 
and is usually attended by a chill and marked eleva- 
tion of temperature. The most reliable diagnostic 
sign is the characteristic putrefactive odor which 
comes from the decomposition of flesh or blood. 
This odor is a positive sign of saprgemia, but the 
same error of technique which allowed the sapro- 
phytes to enter the uterus may have carried pyog- 
enic cocci also, and thus have set up a mixed infec- 
tion. 

Septic Intoxication gives nearly the same initial 
symptoms as does septicaemia, by which it is fre- 
quently followed. After a period varying from two 
to five days the patient has a marked chill or chilly 
sensations, followed by a temperature of 101° to 



ASEPTIC MIDWIFERY. 219 

104° F. and the usual symptoms incident to a sharp 
febrile reaction. There may be pain and tenderness 
over the uterus, but there is not general abdominal 
pain or tenderness. Sometimes the infection occurs 
from perineal or vaginal lacerations. The lochia are 
usually diminished in amount, but the vaginal dis- 
charge may have no offensive odor. Often the worst 
cases of septic infection are not accompanied by 
odor of the discharge, and, when it is marked, it 
shows a concurrent saprsemia. 

Should the localized infection at the placental 
site remain unchecked, either by the granulation tis- 
sue barrier which is often thrown about it or by the 
local treatment employed by the physician, the in- 
fection extends more deeply into the uterine tissue, 
causing a thrombosis of the uterine sinuses, which 
may be the starting point of pyaemia, or the bacteria 
may gain entrance to the circulation directly through 
the blood-stream derived from the uterus, or by a 
septic peritonitis from extension of the disease 
through the uterine tissues. 

Septicaemia usually develops symptoms within 
the first three or five days, with the same symptoms 
as septic intoxication. Should the case be of the 
latter variety, it will often yield promptly to local 
treatment, while septicaemia is progressive in its 
nature, as the bacteria which have gained entrance 
to the blood multiply there and the infection thus 
deepens. 

Pyaemia is usually later in its development than 
the other forms, although it may be preceded by 
any of the other forms of septic infection, and the 
onset of the disease may be masked. It is charac- 



220 SURGICAL ASEPSIS. 

terized by its recurring chills and sweats, irregular 
temperature, and later by secondary abscesses. 

TREATMENT OF PUERPERAL INFECTION. 

This may be briefly outlined by the broad state- 
ment that cases of saprsemia and septic intoxication 
should be treated by removal and disinfection of the 
original depot of infection, while all cases character- 
ized by bacteraemia should be treated locally only so 
far as the absorption of toxins from the original seat 
of infection may be reduced to the minimum. The 
bacteria have already entered the blood in such num- 
bers and multiply with such rapidity that local treat- 
ment is of little avail, and should not be persisted in 
if it exhausts the patient. 

Sapraemia should always be treated by removal 
of the putrefying mass and disinfection of the uter- 
ine canal. Whenever the discharge has the charac- 
teristic putrefactive odor, no time should be lost in 
curettage of the uterus. 

Extreme care must be exercised in all these 
cases that the curette does not penetrate the soft- 
ened uterine tissue and enter the peritoneal cavity. 
A dull or wire curette is to be preferred to a sharp 
one, and its use requires fine tactile sense on the part 
of the operator. 

The curettement is performed in the same man- 
ner as in gynaecological practice, and is followed by 
an intra-uterine douche of sterile water or 1-per- 
cent, lysol solution. The uterine cavity is then dried 
by sterile cotton vvTapped on a uterine sound and 
disinfected as much as possible by the application, 



ASEPTIC MIDWIFERY. 221 

on a cotton-wrapped sound, of a mixture of equal 
parts of tincture of iodine and 95-per-cent. carbolic 
acid. The cavity is then packed with 5-per-cent. 
iodoform gauze, to be removed the following day. 

Should the infection be saprgemic alone, this 
procedure will be followed by a prompt cessation of 
symptoms, while, if it be a mixed infection, an ex- 
cellent culture ground for the pyogenic organisms 
has been removed. The microscope may reveal the 
presence or absence of a mixed infection, but it is 
of little importance. If the odor of the discharges 
indicate the existence of sapraemia, the treatment 
should be a thorough removal of the retained por- 
tions of placenta or blood-clot. 

Septic Intoxication can rarely be distinguished 
at the outset from septicaemia. Whenever a rise 
of temperature exceeding 101° F. occurs during the. 
first week of the puerperium, septic infection should 
be suspected. Should the odor of the discharge be 
not suggestive of sapraemia, the continuance or in- 
crease of this temperature will justify a diagnosis of 
septic infection, unless the fever can be explained 
by some intercurrent affection. 

The diagnosis between septic intoxication and 
septicaemia can rarely be made at this early period, 
but the treatment should be toward the disinfection 
of the infected wound surface. 

Lacerations of the perineum, vagina, or cervix 
should be inspected, and, if they show signs of ne- 
crosis or infection, they should be disinfected by 
prolonged use of bichloride solution 1 to 2000, ap- 
plied by means of a sterile gauze sponge saturated 
with the solution and held against the diseased sur- 



222 SURGICAL ASEPSIS. 

face. Should a superficial necrosis be found, the 
bichloride solution will be ineffective, and the in- 
fected tissue may be treated by 95-per-cent. carbolic 
acid, followed by absolute alcohol. Should the in- 
fection arise from the placental wound, the intra- 
uterine douche should be used every three or four 
hours. Some mild antiseptic solution may be used, 
although any antiseptic which can be safely employed 
in the uterine cavity immediately after delivery can 
have little germicidal power, and certainly cannot 
reach the germs which are below the tissue surface. 
The use of the douche is principally mechanical, by 
washing away the accumulated pus, with its con- 
tained bacteria and their toxins. 

Constant Douching of the uterine cavity was in- 
troduced by Schiicking, and used with success by 
Manseau. It is carried out by siphonage of steril- 
ized water from a receptacle placed above the bed, 
through a rubber tubing and elastic catheter into 
the uterus. The catheter passes through a cervical 
speculum, which is fastened into the cervical canal 
by a silk-worm gut suture. This is a very rational 
procedure, but will not be often used unless it may 
be in hospital practice. 

Curettage, in the absence of retained fragments 
of placenta or other products of conception, should 
not be performed. It breaks down the granulation 
tissue barriers which are being thrown about the in- 
fected tissue, and opens up new avenues for the bac- 
teria to enter the circulation, often changing a septic 
intoxication into septicsemia. 

Disinfection by means of carbolic acid and tinct- 
ure of iodine should not be used, as it destroys only 



ASEPTIC MIDWIFERY. 223 

a part of the infected tissue ; but it also denudes the 
remainder of the uterine cavity of its mucous mem- 
brane, and prepares a large surface for infection by 
the bacilli which are sure to escape destruction by 
the attempted disinfection. 

Hysterectomy for Puerperal Infection. — If the sep- 
tic process progresses, notwithstanding the intra- 
uterine douches, and if the enlargement and soften- 
ing of the uterus, accompanied by uterine tenderness, 
shows a localized infection, we may consider the 
radical removal of the infected organ if we can ex- 
clude the presence of bacterial infection of the blood 
or a septic peritonitis. It is for the prevention of 
these complications that the hysterectomy should be 
done, and, if the infection has extended beyond the 
uterus and appendages, the removal of these organs 
will not stay the disease, but will lessen the power 
of the patient to resist it. 

Unfortunately, the operation, to be successful, 
must be performed early, and in the early stages it 
is often impossible to determine whether the infec- 
tion is purely local or whether bacteria are present 
in the blood. 

Examinations of the blood are not as yet satis.- 
factory in determining the existence of septicaemia, 
and examinations of the lochia do not determine 
whether the infection is local or general. Dr. H. 
J. Boldt considers that the following conditions de- 
mand radical operation, other less heroic measures 
being of no avail : — 

1. If there are no conception products in the 
uterus, and the patient has fever with exacerbations ; 



224 SURGICAL ASEPSIS. 

chills; a small and frequent pulse, from 120 to 140 
or more; if careful observation should show that 
the infection comes from the uterus alone; if there 
is no evidence of peritonitis, the uterus being en- 
larged and relaxed in its consistence, the parametria 
free; if streptococci are found in the uterus and not 
in the blood, hysterectomy is indicated. 

2. If there are decomposition products in the 
uterus (sapraemia) which cannot be removed satis- 
factorily per vaginam, or if on doing a Caesarian sec- 
tion the uterus is found septic, an abdominal hys- 
terectomy is indicated. 

3. Abdominal section with drainage is indicated 
in diffuse septic peritonitis when there is no evidence 
of an exudate in the cul-de-sac of Douglas. The ad- 
nexa are to be left undisturbed, unless there are 
positive indications to do otherwise. 

Doubtless the indications for radical operation 
are as clearly defined by Dr. Boldt as can be done 
at the present time, but the difficulties of an exact 
interpretation of symptoms are so great that it will 
often be found that the uterus has been unnecessarily 
removed or that the disease has extended beyond 
the uterus and its adnexa, and that the operation 
has been futile. 

When a hysterectomy is done for septic infec- 
tion, the vaginal route should usually be selected. 

Septicaemia and Pysemia should be treated after 
the manner advised for these conditions following 
surgical operations. In addition to supporting treat- 
ment, such local disinfection as is not exhausting to 
the patient should be used. This should consist in 



ASEPTIC MIDWIFERY. 225 

frequent vaginal douches with a 1-per-cent. lysol or 
1 to 8000 potassium permanganate sokition, and the 
intra-uterine douche once or twice daily. Should 
any localized abscesses appear, they should be 
drained and irrigated as soon as the presence of 
pus can be determined. 

Antistreptococcic Serum. — For several years anti- 
streptococcic serum has been used by many physi- 
cians for the cure of puerperal infection, with only 
doubtful results. As soon as the first positive re- 
ports reached the medical public, the newly discov- 
ered remedy was used in every variety of infection 
and reports of success or failure were of little value. 
Later, its scientific employment only in those cases 
in which the microscope shows streptococci in the 
lochia are of more value, and at the present time the 
general opinion of the profession at large is that, 
as a therapeutic measure in puerperal sepsis, the use 
of the serum is of very little value. 

In some cases of purely streptococcic infection 
it has seemed to be curative, but the greater part of 
the cases of puerperal sepsis are due to mixed infec- 
tion by streptococci, staphylococci, bacillus coli com- 
munis, etc. 

Even in the cases of purely streptococcic infec- 
tion the varieties of streptococci which may be the 
infecting agent are so many that the antitoxin is of 
uncertain value. 

A fall in the temperature often follows its use, 
but this is not necessarily a good omen, and is con- 
sidered by many observers to be due to the depress- 
ant action of the serum. 

When used it must be early in the disease, and 

15 



226 SURGICAL ASEPSIS. 

may be administered hypodermically in 10-cubic- 
centimeter doses twice daily until from 40 to 60 cubic 
centimeters have been used. If improvement fol- 
lows, the treatment may be continued with dimin- 
ishing doses until the temperature becomes normal. 
Should no improvement follow its use by the time 
that 40 to 60 cubic centimeters have been injected, 
its use should be discontinued. 

Intravascular Antisepsis. — Since a case diagnosed 
at Bellevue Hospital as puerperal septicaemia from 
streptococcic infection was recently reported as 
cured by the intravascular injection of formahn solu- 
tion, much interest has been excited over the possi- 
bility of successfully treating all forms of bactersemia 
by the injection pf antiseptics into the veins. The 
cases which have been treated after this method with 
the exception of the first reported have not been 
encouraging. 

The difficulty which has been mentioned — 
namely, of making a positive diagnosis between 
septic intoxication and septicaemia in the early stages 
of the infection — renders it possible that the case 
may have been one of septic intoxication. 

The most that can be said of this treatment at 
the present time is that the experience in New York 
shows that the intravenous injection of suitable anti- 
septic solutions is not so dangerous as to render their 
use prohibitive. 

In the London Lancet of January 10, 1903, Dr. 
J. M. Fortesque-Brickdale gives a review of the 
subject, with a summary of experiments, made at 
the Jenner Institute of Preventive Medicine. 

Rabbits were used as the subjects of the experi- 



ASEPTIC MIDWIFERY. 227 

nients, and the attempt was made to determine how 
far the injection of various substances into the cir- 
culation was capable of counteracting the effects of 
bacteria or bacterial poisons previously introduced. 
From these experiments the following conclusions 
are drawn : — 

"That rabbits injected daily with non-toxic 
doses of oxycyanide of mercury, formic aldehyde, 
chinosol, protargol, or taurocholate of sodium are 
not thereby protected from the usual effects of a pre- 
vious inoculation of virulent anthrax ; and that chin- 
osol and formic aldehyde in large doses so depress 
rabbits infected with the pneumococcus that they 
die sooner than the untreated animal." 

While a positive opinion of the merits of intrav- 
enous antisepsis should be reserved until the results 
of its further use are observed, it cannot be said to 
have been reasonably established that the case in 
which recovery ensued would have proved fatal 
under other treatment. 



INDEX. 



Abdominal bandage, 12.") 
Absorbent gauze, 70 

cotton, 76 
Absorption of catgut, 87 
Accessions for operation, 140 
Accidental wounds, 2, 152 
After-treatment, 119 
Air infection, 20 
Alcohol, 44 

Aluminum acetate, 148 
Antepartum douche, 203 
Antisepsis, intravascular, 226 
Antistreptococcic serum, 225 
Aristol, 47 

Aseptic midwifery, 197 
Aspiration, 168 

Bacillus tetani, 16, 192 

of tuberculosis, 17 
Bactersemia, 11, 170 

puerperal, 217 
Bandages, 100 
Bladder washing, 165 
Boerckmann's sterilizer, 84 

Carbolic acid, 42 

Catgut, 8}i 

Catheterization, 123, 159 

Celloidin, 99 

Chlorine, 45 

Cleansing of drainage tubes, 92 

Compound fractures, 157 

(^onduct of labor, 204 

Contact infection, 23 



Continuous douching, 222 
Contused wounds, 154 
Cotton wadding, 79 

absorbent, 76 
Curettement, 132 

Decalcified bone chips, 151 
JJouche, 211 

Douching, continuous, 222 
Drainage of wounds, 89 
postural, 89 
tubes, 92 
care of, 92 
Dressing of wounds, 98, 117 
occlusive, 99 

Emergency obstetrical work, 207 
Enema for shock, 120 

saline, 122 
Erysipelas, 182 
Exploratory puncture, 168 

Formaldehyde, 45 
liractional sterilization, 38 
Fractures, compound, 157 

Gauze, absorbent, 76 

diains, 95 

iodoform, 95 

sponges, 77 
(lauze and cotton mops. 78 
(Jutta-peivha tissue, 95 

llulsted's suture. 1 15 



230 



INDEX. 



Hands, disinfection of, 50 
Hypodermic injections, 169 
Hypodermoclysis, 170 
Hjstereccomj for puerperal in- 
fection, 223 

Infected wounds, 147 
Infection, sources, 20 
air, 20 

by contact, 23 
water, 21 
Inflammation, 10 
Instrument sterilizer, GO 

roll, 137 

tables, 69 

trays, 71 
Instrumental labor, 208 
Instruments for amputation, 
145 

for appendicectomy, 142 

for curettage, 140 

for hysterectomy, 144 

for ovariotomy, 143 

for perineorrhaphy, 138 
Intravascular antisepsis, 226 
Iodoform, 47 

gauze, 78 
Irrigating apparatus, 72 

pipes, 72 

Kangaroo tendon, 86 
Krug's frame, 67 

Ligatures, 79 
Lithotomy crutch, 68 
Lysol, 47 

Mattress sutures, 116 
Mercury, bichloride. 41 
oxycyanide, 42 



Nail brush, 50 

cleaner, 50 
Normal salt solution, 62 

Obstetrical patient's outfit, 198 

pad, 199 
Occlusive dressing, 99 
Operating gloves, 54 

pad, 57 

room, 56 

strap, 68 

suits, 73 

tables, 57, 65 
Osteomyelitis, 150 
Oxalic acid, 45 

i-atient, preparation of, 103 
Penetrating wounds, 155 
Perineorrhaphy, 133 
Peritoneal toilet, 111 
Peroxide of hydrogen, 47 
Phagocytosis, 7 
Physician's obstetrical outfit, 

200 
Post-partum douche, 211 
Potassium permanganate, 44 
Preparation of obstetrical bed, 
201 

of obstetrical patient, 202 

of obstetrical room, 201 

of patient, 103 
Puerperal infection, 216 
Pus, 10 
Pysemia, 11, 180 

puerperal, 219, 224 
Pyogenic bacteria, 12 

Removal of sutures, 123 
Repair of lacerations, 209 



INDEX. 



231 



Rubber sheeting, 199 
tissue, 79 • 

Saline enema, 122 
Salt solution, 62 
Sanitary pads, 199 
Sapraemia, 174 

puerperal, 216, 218, 220 
Septic intoxication, 11, 175 
puerperal, 217, 218, 220 
Septicaemia, 11, 176 

puerperal, 219, 224 
Sheets, 74 
Silk, 80 

Silk-worm gut, 80 
Silver wire, 81 
Skin disinfection, 38 
Soap, ethereal antiseptic, 27, 51 

McClintock's germicidal, 27, 
51 

synol, 27, 51 

tincture of green, 26, 51 
Sodium carbonate, 59 
Sponges, 76 

Spore-forming bacteria, 37 
Staphylococcus pyogenes, 12 

epidermidis albus, 13 
Steam sterilizers, 30 
Sterile water, 62 
Sterilization, means of, 25 

by chemical disinfectants, 

39 
by heat, 28 
by washing, 26 



Sterilized animal membrane, 112 
Streptococcus pyogenes, 13 

erysipelatosus, 14 
Suppuration, 10 
Surgical shock, 119 
Suture of wounds, 114 
Sutures, 79 

removal of, 123 

Tables, operating, 57, 65 

instrument, 69 
Temperature after operation, 

124 
Terminal infections, 8 
Tetanus, 190 
Towels, 74 
Trachelorrhapliy, 133 
Traumatic fever, 172 
Trays, instrument, 71 
Trendelenburg position, 67 

Vagina, bacteriology, 126 

disinfection of, 128 
Vaginal operations, 126 

hysterectomy, 130 
Vomiting after ether, 120 
Vulvar obstetrical pads, 199 

\vater for sponging, 62 

infection, 21 
Wounds, accidental, 2, 152 

contused, 154 

drainage of, 89 

dressing of, 98 

penetrating, 155 



MAY 12 1903 



K 



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m^m,!}.^^ 0^ CONGRESS 



021 062 427 2*1 



